SHORT  TALKS 
WITH  YOUNG  MOTHERS 

ON  THE  MANAGEMENT  OF  INFANTS 
AND  YOUNG  CHILDREN 


BY 

CHARLES  GILMORE  KERLEY,  M.D. 

Formerly  Professor  of  Diseases  of  Children,  New  York  Polyclinic  Medical 
School  and  Hospital ;  Attending  Physician  to  the  New  York  Nursery 
and  Child's  Hospital ;  Consulting  Physician  to  the  Babies'  Hospital, 
New  York  ;  Consulting  Physician,  New  York  Home  for  Crippled 
and  Destitute  Children;  Consulting  Pediatrist,  Greenwich  Hospi- 
tal ;  Consulting  Pediatrist,  Savilla  Home,  N.  Y.;  Consulting 
Pediatrist,  Volunteer  Hospital,  N.  Y.,  Consu.lting  Pediatrist 
of  the  Tarry  town  Hospital,  Englewood   Hospital  and 
Lawrence  Hospital,   Bronxville,  N.  Y. 


SEVENTH  EDITION,  REVISED 
ILLUSTRATED 


G.  P.  PUTNAM'S  SONS 

NEW    YORK    AND    LONDON 

fmtcfcerbocfcer  press 


Copyright,  1922 

by 
Charles  Gilmore  Kerley 


Made  in  the  United  States  of  America 


TO 
L.  EMMETT  HOLT,  M.D.,  LL.D. 

THIS  WORK  IS  INSCRIBED 

IN  RECOGNITION  OF  HIS  HIGH  PROFESSIONAL  ATTAINMENTS  AND 

ENTHUSIASM    IN    PROMOTING    THE    STUDY    OF    DISEASES 

OF   CHILDREN,    AND    IN    GRATEFUL   APPRECIATION 

OF   MANY    ACTS    OF   KINDNESS 


500860 


PREFACE  TO  SEVENTH  EDITION 

THE  aim  of  this  book  is  to  help  the 
young  mother  to  a  closer  acquaint- 
ance with  and  a  more  intelligent  apprecia- 
tion of  the  nature  and  demands  of  the 
little  life  entrusted  to  her  care. 

In  its  preparation  the  author  has  kept 
in  mind  and  has  endeavored  to  answer 
the  personal  questions  of  many  thought- 
ful young  mothers.  Under  management  are 
given  such  suggestions  as  may  be  carried  out 
by  the  mother  or  nurse  and  in  no  way  do 
away  with  the  necessity  of  a  physician. 

Suggestions  relating  to  medical  treat- 
ment are  intentionally  avoided.  A  mother 
should  know  all  the  details  of  the  child's 
feeding,  clothing,  bathing,  and  airing,  and 
what  to  do  in  an  emergency.  She  should 
also  be  able  to  recognize  symptoms  of  ill- 
ness and  appreciate  their  significance.  She 
is  not  supposed  to  be  skilled  in  the  use 
of  drugs. 


CONTENTS 

PAGE 

Adenoids .131 

Appetite        .          .                   >.          .  .136 
Artificial  bottle-feeding             ...       60 

Baskets  for  early  exercise         .          .  .     302 

Baths .in 

The  cold  douche       .          .         .  .112 

Tub-baths  for  fever           ..         .  .     114 

Basin  bathing  for  fever     .          .  114 

Bathing  for  comfort  in  hot  weather  .      114 

Mustard  bath           .          ,          .  .     115 

Brine  bath       .          .          .          .  .115 

Soda  bath        .    •       .          .          .  .116 

Bran  bath 116 

Starch  bath     .          .          .          .  .116 

Hot  bath         .          .          .          ,  .116 

Bed- wetting            ...          .        , .  .270 
Bites  of  animals      .....     292 

Bites  of  insects       .          .          .          .  .     292 

Boils     .          .          .          .                    ;  .     236 

Bronchitis      .          .          .          .          »  .164 

Burns   .          .          .          .          .          .  .     292 

Care  of  the  breasts  and  nipples         .  .       48 

Care  of  the  genitals         .         .          .  .273 

Painful  micturition,  circumcision  .     273 
vii 


viii  Contents 

PAGE 

Chicken-pox .                   .          .          .  .187 

Children's  parties             .          .          .  .     302 

Cleanliness    .          .          ....     286 

Clothing  to  be  provided            .          .  .         3 

Cold  hands  and  feet        .  ^       .          .  .     287 

Cold  in  the  head  (coryza)         .          .  .163 

Colic     .          ...          .          .          .  .     256 

Condensed  milk      .  .        .          .          .  .       83 

Constipation           .                 .  .-•        .  .     261 

Management  in  the  breast-fed  .  .262 

Management  in  the  bottle-fed  .  .264 

Management  in  older  children  .     265 

Contagious  diseases         .          . .        .  174 

Convulsions            .          .          .          .  .253 

Cooking  of  vegetables     .          .         *  .       81 

Cough  .          .          .          .          .          v  .157 

Chronic  cough          .          .          .  .158 

Croup — catarrhal,  diphtheritic          .  .167 

Crying            .          .                    .          .  .     284 

Cuts,  bruises,  and  sprains         .          .  .     291 

Dentition  .  .  .  .  .120 

The  breast-fed  '>;  .  .  .  120 

The  well-managed  bottle-fed  .  .121 

The  badly  fed  .  :.  .  .121 

Diet  from  the  first  to  the  eleventh  year  .       73 

Diet  during  illness  ..  .  .  .  -94 

The  art  of  feeding  in  illness  .  .  96 

Diphtheria     .          .          .          .  .184 


Contents  ix 

PAGE 

Disinfection    after    contagious    diseases — 

fumigation             .          .          .  .195 

Don'ts            .          .          .          .  -311 

Drug-giving  .          .          .          .          .  .299 

Earache         .          .          ....  <     117 

Eczema          .          .          .          .  .     222 

The  strait- jacket      .         .         .  .224 

The  mask        .....     226 

Enlarged  tonsils     .          .          .          .  .134 

Excitement    .          .          .          .          .  .280 

Feeding  after  the  first  year      .  -       74 

Fever              .          .          .          .       •  .  .     238 

First  aid  to  the  baby       .          .          .  .291 

Fissures  of  the  anus         .          .          .  .235 

Flies  and  mosquitoes       .          .          .  .288 

Food  formulas        .          .          .          .  . ,   314 

Beef -juice        .          .          .          .  .314 

Beef,  mutton,  and  chicken  broth  .     314 

Scraped  beef    .          .          .          .  .     314 

Egg- water  .    .     315 

Oatmeal  jelly            .          .         ,  .     315 

Wheat  jelly  and  barley  jelly      .  -.315 

Barley-water             :  .     315 

Rice-water       .         .        '.          .  .     315 

Dextrinized  barley-water            .  .     315 

Oatmeal- water          .          .          .  .316 

Imperial  granum- water     .          ,  .316 


x  Contents 

PAGE 

Food  formulas — Continued 

Whey     .          .         .          .  .  .     316 

Junket 316 

Cornstarch  Pudding           .  .  .31? 

Prune  Juice     .          .          .  .  .317 

Soft  Custard   .                   ..  .  .31? 

Coddled  Egg  .          .         .      ;  .  .318 

Foreign  bodies  in  the  ear  and  nose  .  .     295 

Foreign  bodies  swallowed         .  .  .     294 

General  Instructions        .          .          .          .313 

German  measles     .         .  .         .178 

Germs  .  .          .         '.          .          .     289 

Glands  .  ...          .     219 

Acute  enlargement  of  the  glands  of  the 
neck    .          .          .          .          .          .219 

Chronic  enlargement  of  the  glands  of 

the  neck 220 

Grippe  .x         .          .          .          .  *       .     250 

Habits            .          .          .  .  „  .141 

Ear-pulling      .          .  ,  .  144 

The  "pacifier"  habit  .  ,  .      142 

Masturbation            .  .  ,  .145 

Habitual  vomiting           .  .  ,  .  .       99 

Hand-i-hold  mit     .  ,  .  .143 

Head  lice — pediculi  capitis  .  .  .     237 

Height  in  inches  from  birth  to  sixth  year         12 

Hives    .          .-'        ..  .  .  .     228 

How  the  child  should  be  fed  81 


Contents  xi 

PAGE 

How  to  examine  the  throat      .          .          .148 
How  to  lift  the  baby       .          .          .          .12 

Indoor  airing          .          .          .          .       •  .     301 
Intertrigo       ......     230 

Kissing  .          .          .          .          .-         .281 

Malaria          ......  240 

Malnutrition  and  marasmus    .          .  101 

Maternal  nursing   .          .          .          .       .  .  16 

The  diet  .          .          .:  .24 

The  bowel  function            .          .          .  26 
Air  and  exercise        .          .          .          .27 

Regularity  in  nursing        .          .          .28 
Signs  of  successful  nursing         .          .  29 
Signs  of  unsuccessful  nursing     .          .  30 
Signs  of  insufficient  nursing        .          .  35 
Management  of  abnormal  milk  condi- 
tions  .          .                             .          .  35 

Mixed  feeding           ....  38 

Maternal  conditions  under  which  nurs- 
ing is  forbidden    ....  39 

Conditions    which    may    temporarily 

produce  an  unfavorable  effect  upon 

the  breast-milk,  but  not  necessitate 

the  discontinuance  of  nursing          .  39 

Conditions  which  call  for  temporary 

discontinuance  of  nursing       .          .  41 

Care  of  the  nipples  .          .          ...  41 


xii  Contents 

PAGE 

Maternal  nursing — Continued 

Giving  of  water        .          .          .  .42 

Frequency  of  nursing        .          .  -43 

Measles          .         ..'.         .          .          .  .188 

Milk-crust     .          ,         ^        ,.          .  .     229 

Milk  for  travelling                     .  .       .  .       92 

Milk  in  infants'  breasts  .          .          .  135 

Mumps       ..''.:     ...         .  .     179 

Night  terrors         .  .          .          .          .  .     305 

Nose-bleeds  .          .         .         .          .  .     294 

Nursery-maids        .         .       .  .-        .  .128 

Patent  medicines    .                    . .  .     297 

Pneumonia    .          .         ..          .          .  -171 

Premature  and  congenitally  weak  infants  .     213 
Prickly  heat 232 

Retention  of  urine           ,          .          .  .275 

Rheumatism           .      •    ,      <    .-         .  .     249 

Rickets          .          .      •    .          .          .  .     244 

Scales  for  weighing       ,    ,          .          .  .     306 
Scarlet  fever           -..          .         ..   •-       .  .     175 
Scurvy           .        '.          .,         .          .  .     246 
Sick-room  for  contagious  diseases — quar- 
antine     .          .          .          .  .     191 

Disinfectant  drugs   .          .          .  .194 

Sleep     .          .          .          .          .          .  .     282 

Position  when  sleeping      .          .  .12 


Contents  xiii 

PAGE 

Sprue  and  thrush   .          .          .          .  149 

Sterilization    and    pasteurization    of 

milk    ......       56 

Stomatitis,  or  sore  mouth         .          .          .151 
Summer  diarrhoea  .          .          .          .105 

Bowel  irrigation       .          .          .          .109 

Prevention      .       j  .       ..          .          .     no 

Reduction  of  food    .          .          .          .no 

Cleanliness      . '        .       . '  ;       >  ' .          .     in 
Summer  resorts      .....     297 

Taking  cold 153 

Temperature,  and  how  to  take  it      .  .     135 

The  baby-basket  and  its  contents  .         I 

The  care  of  the  eyes        .          .          .  .119 

The  daily  outing    .....     300 

The  delicate  child  .          .          .          .  .      196 

Normal  development         .          .  .     196 

Abnormal  development     .        ' .-.  '  .197 

Management          .  .  '       .          .  197 

Regular  weighings  necessary      .  199 

Feeding  delicate  infants    .          .  .     200 

Diet  after  the  first  year    .          .  .203 

Baths     .          .          .          .          .  .     204 

Fresh  air          .          .          .          .  .     206 

Sleep       .          .          .                   .  .     207 

The  nursery    .        '  .          .          .  .     208 

Influence  of  climate           .         .  .     209 

Clothing         ...          .          .          .  .211 


xiv  Contents 

PAGE 

The  Delicate  Child— Continued 

As  to  the  nature  of  the  clothing  .     211 

Exercise           .          .          .          .  .211 

Midday  nap    .          .         ,          .  .212 

Entertainment       —1.        .          .  •  .     212 

Education       .         .         .         .  .212 

The  exercise  pen    .          .          .          .  .     308 

The  first  duty  to  the  Child      .          .  .         6 

The1  hair               *   .                    .          .  .      127 

The  normal  throat           .       .  ...          .  .  .      146 

The  nursery  .          .          .          .          .  .        14 

The  nursing-bottle  and  nipple .          .  .       59 

The  proprietary  foods     .          ...  .       87 

The   uses   of   proprietary   dried-milk 

foods  .          .          .          .          .  .       89 

Proprietary     foods     to     which     fresh 

cows'  milk  is  added       .          .  .       90 

The  proprietary  beef  foods         .  .  .       92 

The  selection  of  milk       .          .          .  .       53 

The  skin  in  health            .          .          .  .221 

The  teeth      .         .'         .         ,  .     124 

The  care  of  the  teeth         .         ,  125 

The  permanent  teeth        .          .  .     126 

The  trained  nurse            .          .          .  .      129 

The  weight  of  the  well  baby    .          .  .         9 

The  well  baby         .          ...  .         7 

The  wet-nurse         .          .          .  .       .  .       43 

Tonsillitis      .         •.          .          .          .  .162 

Tuberculosis           .         .         .         .  .241 


Contents  xv 

PAGE 

Vaccination  .          .         .  .    '      .  .     268 

Vomiting       .          .          .  .          .  .98 

Weaning        .          .          .  .          .  5° 

Care  of  breasts  during  weaning  ...     52 

When  to  send  for  the  doctor  .          .  .     290 

Whooping-cough    .  .182 

Worms  .  ...     277 

Round- worms           .  .          .  .277 

Thread- worms          .  .          .  ..     278 

Tape- worms    .         .  .         .  -..279 


ILLUSTRATIONS 

PAGE 

Baby-Basket          .         .  .  2 

Nipple-Shield          .         .  /        .42 

English  Breast- Pump  .  .  .  .50 
Freeman  Pasteurizer  .  .  .  .  58 
Nursing  Bottle  and  Nipple  ...  60 
The  Chapin  Dipper  .  .  .  .  66 
Hand-I-Hold  Mit  .....  143 
The  Throat  Examination  .  .  .148 
Cold  Compress  .  .  .  .  .162 
The  Holt  Croup-Kettle  .  .  .169 

Crib  Prepared  for  Steam  Inhalation          .     170 

The  Electrotherm 215 

The  Breck  Feeder  .         .         .         .218 

Strait- Jacket  .....     225 

Strait- Jacket  in  Position  .          .          .     225 

Mask  Pattern         .         .         .         .         .     226 

Mask  in  Position    .         i         .         .         .227 
xvii 


xviii  Illustrations 


PAGE 


The  Bulb  Syringe  .          .          ...        .  .     267 

Basket  for  Early  Exercise         .         .  .     304 

Scoop  and  Platform  Scales  for  Weighing  .     307 

Exercise  Pen  .         .         .         .  .310 


SHORT  TALKS 
WITH  YOUNG  MOTHERS 


SHORT  TALKS 
WITH  YOUNG  MOTHERS 


THE  BABY-BASKET  AND  ITS 
CONTENTS 

(See  Fig.  i.) 

A  BASKET  in  which  all  the  toilet  necessi- 
ties for  the  baby  may  be  kept  together 
will  be  found  a  great  convenience  when  the 
time  for  their  use  arrives. 

To  be  provided : 

A  good-sized  pin-cushion  and  pins. 

Puff-box  and  puff. 

Soap-box  containing  Castile  soap. 

Infant's  hair  brush  and  fine  comb. 

Eight  ounces  of  a  saturated  solution  of 
boracic  acid  for  mouth  and  eyes. 

One-half  pound  of  absorbent  cotton. 

A  package  of  wooden  toothpicks. 

A  bottle  of  white  vaseline. 


2  The  Baby-Basket 

A  bath  thermometer. 
One  yard  of  plain  sterile  gauze. 
Plenty  of  soft  old  linen. 
Six  of  the  best  baby  towels. 


FIG.    I.      BABY-BASKET 


A  white  eiderdown  blanket  one  and  one- 
half  yards  long. 

One  pair  of  small  scissors. 


Clothing  3 

A  package  of  nickel-plated  safety-pins 
(three  sizes). 

CLOTHING 

.  Clothing  required  at  birth. — The  infant  at 
birth  requires  practically  the  same  clothing, 
winter  or  summer — three  flannel  bands,  to  be 
torn  the  desired  length  and  width  according 
to  the  size  of  the  baby.  This  allows  for  a 
band  in  use,  one  to  be  laundered  and  one  for 
emergency.  The  band  is  sewed  on  every 
day,  after  baby's  bath.  Have  the  needle 
ready  for  use  in  a  small  cushion  especially 
for  the  purpose,  and  be  sure  to  replace  the 
needle  when  finished.  We  are  very  certain 
if  the  band  is  put  on  in  this  way  that  baby 
is  not  crying  because  pins  are  sticking  in  him. 

Three  silk  and  wool  (or  cotton  and  wool) 
shirts,  high  neck  and  long  sleeves  (lighter 
weight  for  a  summer  infant). 

Five  dozen  cotton  diapers  (second  size). 

Three  flannel  slips  with  button  and  button 
holes  on  each  shoulder.  This  type  of  gar- 
ment prevents  unnecessary  handling  of  the 
child. 

Six  plain  muslin  slips. 


4  Clothing 

At  six  months. — From  the  third  month  on, 
according  to  the  season,  the  child  may  be  put 
in  short  clothes.  The  little  slips  can  be  cut 
short  and  a  few  new  ones  added.  Eight  in 
all  are  sufficient. 

Three  stockingette  night  slips,  one  easily 
washed  every  morning. 

Three  flannel  petticoats,  and  stockings 
to  cover  the  legs,  as  they  have  been  kept 
very  warm  up  to  this  time.  In  winter  a  silk 
and  wool  (or  cotton  and  wool)  stocking  is 
advisable.  A  woven  band  is  now  used  instead 
of  the  strips  of  flannel.  The  shirts  are  the 
same,  except  if  the  summer  months  have  ar- 
rived the  baby  needs  low  neck  cotton  shirts 
instead  of  woolen  ones. 

The  number  of  diapers  the  baby  requires 
should  now  begin  to  diminish,  for  at  regular 
intervals  he  is  held  on  a  small  chamber  to 
urinate.  If  his  bowels  move  regularly  he  will 
seldom  have  a  soiled  napkin. 

Care  of  diapers. — Remove  when  soiled, 
place  in  covered  pail  filled  with  water  (which 
should  not  be  kept  in  the  nursery),  until  con- 
venient time  for  washing.  Wash  in  hot  water 
using  a  white  soap.  Boil  for  1 5  minutes,  rinse 
thoroughly  and  dry  in  open  air  whenever 


Clothing  5 

possible.  A  rubber  or  water-proof  cover 
should  never  be  used  over  the  diaper.  The 
child  has  greater  freedom  if  the  diapers  are 
folded  in  a  rectangular  shape  instead  of  the 
usual  triangular.  Fasten  on  either  side  with 
two  pins,  one  at  the  waist  line,  one  at  the  side 
of  the  leg.  By  removing  the  two  upper  pins 
the  child  can  be  placed  on  the  chamber  with- 
out removing  the  diapers. 

At  the  first  year. — At  about  this  age  the 
child  will  begin  to  stand,  and  he  must  have 
shoes  to  support  his  ankles.  Rompers  will 
give  him  freedom  and  save  on  the  laundry. 
As  soon  as  he  is  sufficiently  trained  (about  18 
months),  drawers  should  replace  the  diapers. 

Laced  shoes  are  best  for  a  walking  child, 
but  cannot  be  procured  for  a  small  baby. 
When  out  of  doors  in  winter  the  child  should 
have  his  ears  well  covered,  and  a  bonnet  with 
an  interlining  should  be  used.  A  thin 
sweater  is  a  convenient  garment  to  use  under 
the  coat  on  very  cold  days.  The  child  should 
never  go  out  when  the  thermometer  is  under 
I5°F.  A  fine  piece  of  cheese-cloth  may  be 
made  to  fit  the  baby  carriage,  fastened  on  the 
hood,  and  this  will  guard  against  dust  and  the 
high  winds. 


6        First  Duty  to  the  Child 

The  out-of-door  clothing  is  dependent  en- 
tirely upon  the  season  of  the  year  and  with 
the  sudden  changes  which  take  place  in  this 
climate  definite  rules  can  not  be  laid  down. 
Mothers  are  obliged  to  rely  upon  their  own 
judgment,  or  that  of  experienced  friends. 
As  a  general  proposition  it  may  be  said  that 
infants  are  very  apt  to  be  overclad,  particu- 
larly during  the  hot  weather. 

THE  FIRST  DUTY  TO  THE  CHILD 

With  the  severing  of  the  umbilical  cord 
the  child  begins  an  independent  existence. 
It  is  made  to  cry,  the  eyes  and  mouth  receive 
attention,  when  it  is  wrapped  in  a  soft,  warm 
blanket  and  placed  out  of  draughts  until  it 
can  be  given  further  attention.  During  the 
excitement  of  the  occasion  and  the  needs  of 
the  mother  the  baby  is  sometimes  neglected, 
often  with  serious  consequences.  I  once 
saw,  with  another  physician,  a  fatal  case  of 
pneumonia  in  a  child  four  days  old,  the  dis- 
ease being  due  in  all  probability  to  neglect. 
It  must  not  be  forgotten  that  the  baby  has 
been  suddenly  transported  into  an  entirely 
'different  sphere  of  action  from  that  to  which 


The  Well  Baby  7 

he  is  accustomed,  and  we  must  make  the 
change  as  easy  for  him  to  bear  as  possible. 
As  soon  as  the  nurse  can  devote  her  attention 
to  the  baby  he  should  be  gently  and  thor- 
oughly oiled  with  liquid  albolene  or  sweet  oil. 
This  is  to  be  followed  later  by  a  sponge  bath 
with  lukewarm  water  and  Castile  soap.  The 
stump  of  the  cord  should  be  dusted  with  some 
dry  antiseptic  powder  and  wrapped  in  dry, 
plain  sterile  gauze.  The  cord,  particularly 
at  its  junction  with  the  abdomen,  should  be 
thoroughly  dusted  twice  a  day.  When  it  falls 
off,  the  parts  should  be  kept  dusted  and 
dry  until  cicatrization  is  complete.  The 
following  powder  has  proven  most  satisfac- 
tory in  my  hands : 

Salicylic  acid,  15  grains. 
Powdered  starch,  I  ounce. 
Powdered  oxide  of  zinc,   i  ounce. 

THE  WELL  BABY 

In  order  to  appreciate  disease  or  failure  in 
proper  growth  and  development,  it  is  neces- 
sary to  know  what  constitutes  a  well  baby. 
The  well  baby  grows  steadily,  shows  an  in- 
crease in  weight  of  from  five  to  six  ounces  a 


8  The  Well  Baby 

week,  the  muscles  are  firm,  the  skin  clear, 
and  the  eyes  bright.  When  hungry  he  makes 
it  known  by  crying  lustily.  At  the  com- 
pletion of  the  feeding  he  gives  evidence  of 
comfort  by  drowsiness,  or  by  falling  asleep. 
There  are  two  or  three  soft  orange  yellow 
stools  daily.  After  the  second  month  the  well 
baby  appreciates  a  moderate  amount  of  atten- 
tion, and  is  attracted  to  bright  objects  and 
pleasant  faces.  His  sleep  is  restful  and  he 
wakes  good-natured  unless  he  is  hungry.  It  is 
not  to  be  understood  that  the  well  baby  cries 
only  when  hungry.  He  often  cries  while  being 
undressed,  when  the  clothing  is  uncomfortable, 
when  objectionable  people  appear  before  him, 
or  when  suffering  from  pain. 

At  the  fourth  or  fifth  month  he  should  be 
able  to  hold  his  head  erect  without  support; 
from  the  sixth  to  the  seventh  month — at 
this  time  the  first  tooth  is  usually  cut — he 
acquires  the  power  of  sitting  up  without  assist- 
ance; from  the  ninth  to  the  tenth  month  he 
begins  to  creep,  and  from  the  twelfth  to  the 
eighteenth  month  he  learns  to  walk  alone.  A 
very  few  children  walk  alone  before  the 
twelfth  month;  the  great  majority,  however, 
are  from  fifteen  to  eighteen  months  before 


Weight  of  the  Well  Baby      9 


this  important  feat  is  accomplished.  There 
is  nothing  to  be  gained  and  much  harm  may 
be  done  by  parents  favoring  early  walking. 
When  the  child  learns  to  walk  unaided,  it  is 
usually  safe  to  allow  him  to  continue,  unless 
he  is  very  heavy.  A  child  four  or  five  pounds 
over  weight  should  be  carefully  watched  and 
the  walking  prevented  to  any  extent  until  he  is 
seventeen  or  eighteen  months  of  age.  Early 
walking  in  these  heavy  children  is  very  apt 
to  produce  flat  feet,  knock-knee,  or  bowed- 
legs. 

THE  WEIGHT  OF  THE  WELL  BABY 


BOYS 

GIRLS 

Average  weight  at  birth 

7-55  Ibs. 

7.i61bs 

ii 

4  three  months 

ii-75 

U-5 

n 

1  six  months 

16. 

15-5 

u 

'  nine  months 

18. 

1775 

u 

'  twelve  months 

20. 

19.8 

ii 

'  eighteen  months 

22.8 

22. 

i« 

1  two  years 

26.5 

25-5 

u 

' 

'  three  years 

31.5 

30. 

M 

1  four  years 

35- 

34- 

14 

'  five  years 

41.2 

39-8 

i« 

'  six  years 

45-1 

| 

43-8 

Weighing    the    baby. — Every    child    under 
one  year  of  age  should  be  weighed  once  a 


io     Weight  of  the  Well  Baby 

week.  The  very  weak  and  delicate  and 
those  who  are  being  put  through  a  new  course 
of  dietetic  treatment  on  account  of  failure  in 
growth,  should  be  weighed  two  or  three  times 
a  week. 

Gain  in  weight. — An  infant  is  doing  fairly 
well  who  gains  on  an  average  four  ounces  a 
week,  ten  months  in  the  year.  Such  a  child, 
however,  needs  careful  watching.  If  he  gains 
six  ounces  a  week,  we  are  perfectly  satisfied 
with  his  progress. 

The  weight  chart. — The  use  of  the  weight 
chart  I  do  not  advise.  Such  a  chart,  while 
recommended  by  many  well-known  writers, 
has  been  the  cause  of  serious  trouble.  The 
mother  and  nurse  wish  the  baby's  weight 
chart  to  make  a  good  showing — to  show 
something  phenomenal  if  possible — for  the 
admiration  of  relatives  and  friends.  Some 
perfectly  well,  vigorous  babies  increase  in 
weight  slowly,  but  a  gain  of  only  four  or  five 
ounces  a  week — below  the  standard  of  her 
neighbor  or  the  normal  weight  line  on  the 
chart — makes  a  very  unsatisfactory  chart, 
and  the  mother  in  consequence  begins  to  worry, 
fearing  that  her  baby  is  not  being  properly 
nourished.  Worry  and  anxiety  have  caused 


Weight  of  the  Well  Baby     1 1 

the  milk  of  hundreds  of  mothers  to  fail,  and 
rendered  further  nursing  impossible.  If  the 
babe  is  wet-nursed  and  the  chart  does  not  show 
a  large  gain,  the  mother  is  unhappy,  the  family 
generally  is  dissatisfied,  the  wet-nurse  sulks, 
and,  fearing  lest  she  lose  her  position,  her 
milk  soon  fails  and  she  is  unable  to  nurse 
the  baby.  If  the  baby  is  bottle-fed,  there 
is  a  strong  tendency  to  overfeed  him  in  order 
to  make  a  pretty  chart,  and  as  a  result  the  child 
is  made  ill. 

The  gain  in  weight  is  much  less  in  summer 
than  during  the  cooler  months.  I  have  seen 
many  children  in  perfect  health  pass  through 
July  and  August  without  gaining  an  ounce; 
but  with  the  arrival  of  cooler  weather  they  will 
surely  make  up  for  the  time  lost. 

Early  loss  in  weight. — There  is  usually 
a  decided  loss  in  weight  the  first  four  days 
of  life.  This  loss — from  a  quarter  to  a  half 
pound — will  usually  be  regained  in  five  or  six 
days  if  the  child  is  properly  fed. 

Weight  at  age  of  one  and  two  years. — At 
the  end  of  the  first  year  the  child  should  weigh 
two  and  one-half  times  as  much  as  at  birth. 
There  should  be  a  gain  of  about  seven  pounds 
during  the  second  year. 


12  Height  in  Inches  from  Birth 

HEIGHT  IN  INCHES  FROM  BIRTH  TO 
SIXTH  YEAR 


At  birth 

6  months 

12  months 

Boys,   20.6 
Girls,   20.5 

25-4 
25 

29 
287 

18  months 
Boys,    30 
Girls,   29.7 

Two  years 
32.5 
32.5 

Three  years 
35 
35 

Four  years 
Boys,    38 
Girls,    38 

Five  years 

417 
41.4 

Six  years 
44.1 
43-6 

HOW  TO  LIFT  THE  BABY 

A  baby  should  be  lifted  by  placing  one  hand 
under  the  buttocks  and  the  other  under  the 
head.  Until  the  fifth  or  sixth  month  is 
reached,  a  child  should  never  be  raised  with 
head  unsupported* 

POSITION  WHEN  SLEEPING 

It  is  best  to  train  the  baby  to  rest  on  his 
stomach  when  sleeping.  This  helps  to  give  the 


Position  When  Sleeping      13 

child  a  more  erect  figure  later  on.     A  pillow 
should  never  be  used. 

It  is  much  more  convenient  when  dressing 
or  changing  the  baby  if  he  is  placed  on  a  small 
table. 


THE  NURSERY 

The  nursery  should  be  the  largest  and  best 
ventilated  bedroom  in  the  house.  In  a  city 
home  it  is  best  to  have  it  on  the  third  or 
fourth  floor  with  a  southern  exposure.  In 
apartments,  quiet  and  the  possibility  of  free 
ventilation  and  sunlight  must  be  considered 
in  selecting  the  room.  For  the  sake  of  quiet 
the  nursery  should  not  communicate  with  the 
sleeping-rooms  of  older  children. 

Air  capacity  of  sleeping-room. — In  placing 
children  in  sleeping-rooms  or  in  a  nursery,  or 
in  estimating  the  capacity  of  hospital  wards 
for  children,  it  is  to  be  remembered  that  at 
least  one  thousand  cubic  feet  of  air-space 
should  be  allowed  to  each  child. 

The  floor  of  the  nursery  should  not  be 
carpeted.  A  hard- wood  floor  is  best.  If  this 
is  not  possible,  covering  the  floor  with  oil- 
cloth or  linoleum  is  always  possible.  This  can 
be  cleaned  with  a  damp  cloth  every  day.  A 
broom  should  never  be  used  in  a  nursery. 
Paint  or  hard  finish  on  the  walls  is  preferable 
14 


The  Nursery  15 

to  paper.  There  should  be  at  least  two  win- 
dows and  an  open  fireplace.  If  possible,  the 
bath-room  should  be  connected  with  the  nurs- 
ery, to  be  used  not  only  for  bathing  the  child 
but  as  a  "changing  room."  The  child's  nap- 
kins should  not  be  changed  in  its  living-room 
if  it  can  be  avoided.  It  is  needless  to  say  that 
napkins  should  never  be  dried  in  the  nursery. 

Furnishings. — The  furniture  of  the  nursery 
should  be  of  the  plainest.  Hard-wood  chairs 
and  tables  with  enamel  or  brass  cribs  or  bed- 
steads should  be  used.  There  should  be  no 
article  of  furniture  or  furnishings  in  a  nursery 
that  cannot  be  washed. 

There  should  be  two  shades  at  each  win- 
dow, a  light  and  a  dark  shade,  so  that  it  will 
be  possible  to  darken  the  room  during  the 
sleeping  time,  as  well  as  to  exclude  the  early 
morning  light,  which  is  the  usual  cause  of  too 
early  waking.  Babies  should  be  taught  to 
sleep  until  at  least  six  o'clock  in  the  morning. 
This  is  far  better  for  the  child  and  also  for 
the  mother  if  she  occupies  the  same  room. 
The  unnecessary  habit  of  an  early  waking  at 
four  or  five  o'clock  will  in  most  instances 
readily  be  broken  by  keeping  the  room  dark. 

Ventilation.  —  The    nursery    should    have 


i6  Maternal  Nursing 

suitable  means  for  ventilation.  For  this  pur- 
pose, aside  from  the  fireplace,  I  have  found 
the  window  board  of  no  little  service  in  cold 
weather.  It  can  be  made  of  any  width. 
Ordinarily,  I  have  it  made  about  four  inches 
wide.  It  is  sawed  so  as  to  fit  tightly  under  the 
lower  sash.  This  leaves  an  open  space  corre- 
sponding to  the  width  of  the  board  between 
the  upper  and  lower  sash,  and  allows  the  en- 
trance of  a  current  of  air  which  is  directed 
upward. 

Room  temperature. — There  should  be  a 
thermometer  in  every  child's  living-room  or 
nursery.  It  should  register  from  65°  to  68a 
F.  by  day  and  from  50°  to  60°  F.  by  night. 
The  nursery  should  be  given  an  hour's  airing 
twice  a  day.  The  child  should  sleep  alone  in 
its  crib.  It  should  not  sleep  with  an  adult  or 
an  older  child. 

MATERNAL  NURSING 

Writers  on  this  subject  are  very  apt  to 
state  that  the  ability  of  the  mother,  particu- 
larly among  the  well-to-do,  to  fulfill  this  most 
important  function  is  surely  decreasing.  This 
may  have  been  a  true  statement  several  years 


Maternal  Nursing  17 

ago;  at  the  present  time,  however,  I  am  sure 
it  is  erroneous.  In  my  own  medical  life  I 
have  seen  a  change  for  the  better,  particularly 
during  the  past  ten  years.  The  young  mother 
of  to-day  is  better  able  to  nurse  her  offspring 
than  was  her  own  mother.  I  attribute  this  to 
the  fact  that  the  youth  of  the  present  day  are 
more  vigorous,  more  nearly  normal  individuals 
than  were  their  grandparents.  The  inability 
to  perform  the  nursing  function  so  that  it  will 
be  successful  has  always  been  attributed  to  the 
mother  per  se.  This,  I  think,  is  an  error.  Not 
every  breast-milk  for  two  or  three  weeks 
after  parturition  is  ideal,  as  I  have  found  by 
the  examinations  of  hundreds  of  them.  If  a 
child  is  born  with  a  generally  enfeebled  vital- 
ity, it  keenly  feels  any  slight  abnormality  in 
the  milk,  or  it  may  not  be  able  to  digest  per- 
fectly normal  milk;  in  either  event,  the  milk 
disagrees  and  the  nursing  is  discontinued. 
Breast-milk  during  the  first  two  or  three 
weeks  of  the  infant's  life  is  produced  under 
conditions  which  are  unfavorable — conditions 
which  do  not  indicate  the  possibilities  of  the 
breast  as  a  secreting  organ.  Following,  as  it 
does,  upon  the  stress  of  confinement,  it  is  not 
indicative  of  what  may  be  possible  later  when 


1 8  Maternal  Nursing 

the  customary  life  and  daily  habits  are  re- 
sumed. Repeatedly  I  have  found  overrich 
milk  or  very  poor  milk  during  the  first  week 
or  two,  entirely  corrected  later  without  inter- 
ference. 

Influence  of  the  daily  life. — The  change 
which  enables  more  mothers  successfully  to 
nurse  their  infants  is  due  to  two  causes — 
more  vigorous  fathers  and  mothers  and  more 
vigorous  offspring.  Following  this  line  of 
reasoning,  the  more  normal  the  mother,  the 
better  able  is  she  to  perform  this  normal  func- 
tion. That  this  is  the  case  is  due,  I  believe, 
to  the  fact  that  growing  girls  and  young 
women  are  leading  more  hygienic  lives  than 
formerly.  The  making  of  golf,  bicycle  and 
horseback  riding,  boating,  and  automobiling 
popular  and  fashionable — in  short,  the  taking 
of  girls  out-of-doors  and  keeping  them  there 
a  considerable  portion  of  the  day — has  worked 
a  marvellous  change  for  the  better,  both  physi- 
cally and  mentally.  A  neurotic  mother  makes 
the  poorest  possible  milk-producer.  Propor- 
tionate to  the  population,  there  are  fewer 
neurasthenics  among  the  young  women-  to-day 
than  there  were  twenty  years  ago,  and  there 
will  be  still  fewer  twenty  years  hence.  At  the 


Maternal  Nursing  19 

present  time  the  timid,  retiring  young  woman 
of  the  neurasthenic  type  is  not  popular  in  her 
set.  It  is  a  fortunate  thing  for  the  future  of 
the  human  race,  at  least  for  that  portion  of  it 
which  resides  in  the  United  States,  that  the 
young  woman  has  transferred  her  allegiance 
from  the  crochet  and  embroidery  needle  to  the 
golf  club. 

Better  living  practice  pervades  all  classes. — 
It  may  be  said  that  our  argument  holds  only 
with  the  wealthy  or  the  well-to-do.  Imita- 
tion is  one  of  the  strongest  characteristics 
of  the  human  race,  and  this  tendency  in 
America  to  outdoor  hygienic  living  pervades 
all  classes.  Saturday  half -holidays,  the  ex- 
cursions and  outings  afforded  by  reduced 
rates  of  transportation,  are  much  more  popu- 
lar than  they  were  ten  years  ago.  Food  is 
better  selected  and  better  prepared,  owing  to 
increased  knowledge  on  the  part  of  the  people 
as  to  what  constitutes  proper  nutrition. 

The  teaching  of  right  living. — A  feature 
which  marks  an  important  advance  in  the 
right  direction  is  the  establishment  of  a  de- 
partment in  dietetics  and  food  economics  in 
the  New  York  Training  School  for  Teachers. 
The  Dean,  Dr.  James  E.  Russell,  in  establish- 


20  Maternal  Nursing 

ing  this  course,  is  producing  benefits  which 
reach  farther  than  he  realises.  The  students 
are  taught  food  values,  food  preparation,  and 
food  economics,  which  consist  in  providing 
for  a  given  amount  of  money  the  most  nutri- 
tious food  in  its  most  attractive  form.  Hun- 
dreds of  teachers  are  sent  out  from  this  insti- 
tution every  year  to  take  their  places  of  use- 
fulness as  instructors  of  the  young  in  all  por- 
tions of  the  country.  Each  has  learned  some- 
thing of  food  values,  and  better  still  each  has 
had  impressed  upon  him  or  her  the  importance 
of  the  proper  nutrition  of  a  growing  child. 
They  are  taught  that,  without  this,  the  best 
possible  type  of  adult  cannot  be  produced.  As 
a  result  of  such  instruction  they  will  be  of  far 
greater  service  in  their  fields  of  labor,  for  not 
only  can  they  teach  what  is  laid  down  in  the 
books,  but,  what  is  equally  if  not  more  impor- 
tant, they  are  competent  to  teach  those  under 
their  care  how  to  live;  and  those  who  live 
properly,  grow  properly,  following  out  the 
maxim  of  Herbert  Spencer  that  ''the  first 
requisite  for  success  in  life  is  to  be  a  good 
animal;  and  to  be  a  nation  of  good  animals 
is  the  first  condition  of  national  prosperity." 
It  may  be  thought  that  we  have  wandered  far 


Maternal  Nursing  21 

from  our  subject — maternal  nursing,  but  such 
is  not  the  case;  for  conditions  which  relate  to 
this  important  function,  even  remotely,  demand 
our  respectful  consideration.  The  food  and 
care  of  the  growing  girl  have  the  most  inti- 
mate bearing  upon  her  future  life,  and  if  she 
is  to  be  called  upon  to  perform  the  most  im- 
portant function  of  womanhood,  she  surely 
has  the  right  to  demand  that  she  receive  dur- 
ing her  girlhood  proper  preparation,  which 
heretofore  has  too  often  been  denied  her. 

The  duty  of  the  physician. — It  is  not 
pleasant  to  criticise  physicians;  but  friendly 
criticism  should  always  be  welcomed.  The 
family  physician  does  not,  in  a  great  majority 
of  instances,  fulfill  his  function,  or  extend 
his  field  of  usefulness  to  its  full  capacity,  his 
conception  of  duty  too  often  including  only 
the  sick.  Unsought  advice  as  to  the  feeding 
and  daily  habits  of  a  child's  life,  I  find,  are 
usually  welcomed  and  appreciated  by  mothers. 
In  practically  every  instance,  according  to 
my  observation,  errors  in  a  child's  manage- 
ment are  due  to  ignorance.  Mothers,  no 
matter  what  their  station  in  life,  are  glad  to 
do  what  is  for  the  best  interests  of  their 
children  when  it  is  made  clear  to  them.  It  is 


22  Maternal  Nursing 

the  duty  of  the  physician  to  take  the  mother 
into  his  confidence  and  explain  to  her  the 
reasons  for  the  line  of  action  advised.  When 
she  appreciates  the  reason  for  certain  pro- 
cedures, I  find  that  she  is  far  more  apt  to  fol- 
low them. 

Possibilities  under  right  management. — I 
am  confident  from  observations  upon  many 
cases  that  if  I  could  have  the  physical  direc- 
tion of  ten  average  girls  in  any  station  in  life, 
provided  that  they  could  have  the  benefit  of 
fresh  air  and  good  food  from  infancy  to 
adolescence,  successful  nursing  mothers  could 
be  made  out  of  eight  of  them. 

Requirements  for  successful  nursing. — Cer- 
tain rules  of  life  having  a  direct  bearing  on 
nursing  lead  us  nearer  the  ideal  and  may  en- 
able one  who  otherwise  could  not  nurse  her 
child  to  do  so  successfully.  These  require- 
ments, it  will  be  seen,  are  laid  along  common- 
sense  lines  and  cause  no  hardships  or  mental 
distress — one  of  the  chief  requirements  of  a 
nursing  woman  being  that  she  shall  be  men- 
tally well  balanced  and  carry  out  the  sugges- 
tions that  will  follow. 

There  are  few  conditions,  in  which  we  are 
called  to  act,  so  variable  and  so  uncertain  as 


Maternal  Nursing  23 

is  the  production  of  breast-milk.  Breast-milk 
is  one  of  the  most  precious  substances.  It  is 
invaluable,  unless  we  can  put  a  value  on  human 
life. 

Successful  nursing  age. — The  most  success- 
ful nursing  age  is  between  the  twentieth  and 
thirty-fifth  years.  I  have,  however,  seen  it 
successfully  carried  on  in  a  girl  of  fourteen, 
in  a  woman  of  fifty-two,  and  in  the  much- 
abused  society  girl,  while  I  have  seen  it  fail 
absolutely  in  peasant  women  fresh  from  the 
fields  of  Hungary  and  Bohemia.  I  have 
seen  those  in  whom  at  first  the  nursing  was 
most  unsatisfactory  develop  into  perfect 
nurses. 

Duration  of  nursings. — Some  mothers  will 
be  able  to  carry  on  the  nursings  for  only  two 
months;  others,  three,  five,  seven,  or  nine 
months.  In  my  experience,  whether  in  out- 
patient or  in  private  practice,  it  is  extremely 
rare  for  the  breast-milk  to  be  sufficient  for 
the  child  after  the  ninth  month. 

The  following  can  be  laid  down  as  nursing 
axioms : 

A  diet  similar  to  what  the  mother  was 
accustomed  to  before  the  advent  of  mother- 
hood should  be  taken. 


24  Maternal  Nursing 

There  should  be  one  bowel  evacuation  daily. 

There  should  be  from  three  to  four  hours 
daily  spent  in  the  open  air  with  exercise  which 
does  not  fatigue. 

There  should  be  at  least  eight  hours'  sleep 
out  of  every  twenty- four. 

There  should  be  absolute  regularity  in 
nursing. 

There  should  be  no  worry  and  no  excite- 
ment. 

The  mother  should  be  temperate  in  all 
things. 

The  diet. — I  have  many  times  been  con- 
sulted by  nursing  mothers  because  the  nursing 
was  unsuccessful  or  a  partial  failure,  and  have 
found  that  their  diet  has  been  restricted  to  an 
extreme  degree.  To  put  on  a  greatly  restricted 
diet  a  robust  young  mother  who  has  always 
eaten  bountifully  of  a  generous  variety  of 
foods  is  one  of  the  best  means  of  curtailing 
the  quantity  and  lowering  the  quality  of  her 
milk-supply.  When  asked  to  prescribe  a  diet 
I  tell  them  to  eat  practically  as  they  were  accus- 
tomed to  before  the  advent  of  pregnancy  and 
motherhood.  That  this  particular  vegetable 
or  that  particular  fruit  should  be  forbidden,  on 
general  principles  is  a  fallacy.  Food  that  the 


Maternal  Nursing  25 

patient  can  digest  without  inconvenience  is  a 
safe  food  so  far  as  the  nursing  is  concerned, 
as  may  readily  be  determined  in  any  given 
case.  If  a  wide  range  of  diet  is  prescribed  in 
some  individuals,  a  plain,  more  or  less  re- 
stricted diet  is  desirable  in  others.  Many  a 
wet-nurse  who  has  been  carefully  selected,  who 
to  the  best  of  our  judgment  should  prove  satis- 
factory, utterly  fails  in  a  few  days  to  fulfill  the 
duties  of  the  office  for  which  she  was  chosen. 
In  not  a  few  instances  the  failure  is  due  to  a 
very  full  diet  of  unusual  articles  of  food,  the 
existence  of  which,  in  many  instances,  she 
never  dreamed.  Indigestion  and  constipation 
follow,  and  both  the  nurse  and  the  baby  are 
made  ill  and  the  woman's  usefulness  ceases. 
A  woman  who  has  lived  and  been  well  on  the 
diet  and  food  found  in  the  home  of  the  labor- 
ing man,  whether  in  the  city  or  country,  will 
make  a  far  better  wet-nurse  on  this  diet  than 
if  she  indulges  in  food  to  which  she  is  entirely 
unaccustomed. 

Nursing  is  a  perfectly  normal  function,  and 
a  mother  should  be  permitted  to  carry  it  out 
along  only  natural  lines.  Inasmuch  as  there 
are  two  lives  to  be  provided  for  instead  of  one, 
more  food,  particularly  of  a  liquid  character, 


26          Maternal  Nursing 

may  be  taken  than  she  may  have  been  accus- 
tomed to.  It  is  my  custom  to  advise  that  milk 
be  given  freely.  A  glass  of  milk  may  be  taken 
in  the  middle  of  the  afternoon,  and  eight 
ounces  of  milk  with  eight  ounces  of  oatmeal  or 
cornmeal  gruel  at  bedtime,  if  it  does  not  dis- 
agree. Our  only  evidence  that  a  food  is  not 
disagreeing  is  the  condition  of  the  digestion. 
When  any  article  of  food  disagrees  with  the 
mother,  or  if  she  is  convinced  that  it  disagrees, 
whether  or  not  such  is  really  the  case,  the  food 
should  be  discontinued.  In  a  general  way, 
milk  in  quantities  not  over  one  quart  daily, 
eggs,  meat,  fish,  poultry,  cereals,  green  vege- 
tables, and  stewed  fruit  constitute  a  basis  for 
selection.  The  method  of  preparation  for  the 
different  meals  is  not  arbitrary. 

The  bowel  function. — A  very  important  and 
often  neglected  matter  in  relation  to  nursing 
is  the  condition  of  the  bowels.  There  must  be 
one  free  evacuation  daily.  For  the  treatment 
of  constipation  in  nursing  women  I  have  used 
different  methods  in  many  cases.  The  dietetic 
treatment  does  not  promise  much.  For  here, 
again,  manipulation  of  the  diet  may  interfere 
with  the  milk  production.  Three  methods  are 
open  to  use :  massage,  local  measures,  and 


Maternal  Nursing  27 

drugs.  Massage  is  available  in  comparatively 
few  cases.  Local  measures  consist  in  the  use 
of  enemas  or  suppositories.  Every  nursing 
woman  under  my  care  is  instructed  to  use  an 
enema  at  bedtime  if  no  evacuation  of  the 
bowels  has  taken  place  during  the  previous 
twenty- four  hours.  Many  out-patients,  in 
whom  constipation  is  very  prevalent,  indulge 
in  excessive  tea-drinking,  taking  often  from 
one  to  two  gallons  of  tea  daily.  In  such 
patients,  where  an  absolute  discontinuance  of 
the  tea-drinking  is  often  impossible  and  not  ab- 
solutely necessary,  I  usually  allow  two  cups  a 
day.  When  a  laxative  is  necessary,  it  should 
be  prescribed  by  a  physician. 

Air  and  exercise. — Outdoor  life  and  exercise 
are  desirable  here  as  they  are  under  all  other 
conditions.  In  a  nursing  woman,  with  her 
added  responsibility,  they  are  doubly  so.  In 
order  to  get  the  best  results,  exercise  or  work 
should  so  be  adjusted  as  not  to  reach  the  point 
of  fatigue.  The  mother  whose  nights  are  dis- 
turbed should  be  given  the  benefit  of  a  midday 
rest  of  an  hour  or  two.  She  should  have  at 
least  eight  hours'  sleep  out  of  every  twenty- 
four.  Certain  annoyances,  anxieties,  and  wor- 
ries are  inseparable  from  the  life  of  every 


28  Maternal  Nursing 

child-bearing  woman.  It  should  be  our  duty, 
however,  to  explain  to  the  mother  and  to  other 
members  of  the  family  that  an  important  ele- 
ment in  satisfactory  nursing  is  a  tranquil 
mind.  During  the  lactation  period  she  should 
be  spared  all  unnecessary  care  and  petty  annoy- 
ances. 

Regularity  in  nursing. — The  breast  which  is 
emptied  at  definite  intervals  invariably  works 
better  than  does  one  which  is  not,  not  only  as 
regards  the  quantity,  but  the  quality  of  the 
milk  as  well;  so  that  system  in  breast-feeding 
is  almost  as  essential  to  milk-production  as 
to  its  digestion  and  assimilation. 

In  the  vast  majority  of  cases  it  is  best  to 
use  one  breast  at  a  time.  Rarely  the  nursing 
will  be  better  carried  on  when  both  are  used 
at  each  feeding. 

The  use  of  one  bottle  a  day. — After  it  is 
demonstrated  that  the  nursing  is  progressing 
satisfactorily  as  proved  by  the  satisfied,  thriv- 
ing child,  I  begin  with  one  bottle-feeding  daily. 
The  advisability  is  obvious;  in  case  of  illness 
of  the  mother,  if  she  is  called  away  from  home, 
or  if,  for  any  reason,  the  child  cannot  have  the 
breast,  the  feeding  is  provided  for.  Another 
advantage  is  that  it  gives  the  mother  needed 


Maternal  Nursing  29 

freedom  from  restraint.  She  is  thus  enabled 
to  have  the  benefit  of  a  change  of  scene. 
Amusements  and  recreations  which  the  in- 
variable nursing  period  denies  her  can  be 
indulged  in.  As  a  result  of  this  greater  free- 
dom, she  is  able  to  supply  better  milk  and  to 
continue  nursing  longer  than  if  tied  continually 
to  the  baby,  no  matter  how  fond  she  may  be 
of  it. 

Signs  of  successful  nursing. — The  child 
shows  a  gain  of  not  less  than  four  ounces 
weekly.  This  is  the  minimum  weekly  gain 
which  may  safely  be  allowed.  When  a  nurs- 
ing baby  remains  stationary  in  weight  or 
makes  a  gain  of  but  two  or  three  ounces  a 
week,  it  means  that  something  is  wrong,  and 
it  will  usually,  but  not  invariably,  be  found 
in  the  milk  supply.  When  the  baby  is  nursed 
at  proper  intervals  and  the  supply  of  milk  is 
ample  and  of  good  quality,  he  is  satisfied  at 
the  completion  of  the  nursing.  If  he  is  under 
three  months  of  age,  he  falls  asleep  after  ten 
or  twenty  minutes  at  the  breast.  When  the 
nursing  period  again  approaches,  he  becomes 
restless  and  unhappy,  crying  lustily  if  the 
nursing  is  delayed.  When  the  breast  is  offered, 
he  takes  it  greedily.  The  stools  are  yellow 


30  Maternal  Nursing 

and  number  from  two  to  three  daily.  The 
weekly  gain  in  weight  under  such  conditions 
is  usually  from  six  to  eight  ounces. 

Signs  of  unsuccessful  nursing. — Theoreti- 
cally, every  normal  breast  baby  should  be  a 
thriving,  well  baby.  That  such  is  not  the  case 
is  an  unfortunate  fact.  The  standard  estab- 
lished for  a  well  baby  is  not  upheld  here.  When 
the  supply  of  milk  is  scanty  the  child  remains 
long  at  the  breast  and  cries  when  he  is  re- 
moved. He  shows  signs  of  hunger  before 
the  nursing  hour  arrives.  A  course  of  failure 
in  breast-feeding,  and  probably  the  most  fre- 
quent cause,  is  a  scanty  milk-supply.  The 
chief  nutritional  elements  in  mother's  milk 
are :  fat,  3  to  4  per  cent. ;  sugar,  7  per  cent. ; 
proteid,  1.5  per  cent.  Failure  may  be  due  to  a 
marked  disproportion  of  these  elements,  which 
may  cause  sufficient  indigestion  and  resulting 
loss  in  weight  to  necessitate  the  discontinuance 
of  nursing.  Thus  there  may  be  a  high  fat — 
from  5  to  6  per  cent. ;  or  very  low  fat — from 
i  to  1.5  per  cent.  In  the  high-fat  cases  there 
will  usually  be  diarrhoea  with  green,  watery 
stools.  The  child  strains  a  great  deal  and 
there  are  green  stains  on  many  of  the  napkins. 
In  high- fat  cases  there  is  also  regurgitation  or 


Maternal  Nursing  31 

vomiting  of  sour  material.  Low  fat  means 
deficient  nourishment  and  may  cause  constipa- 
tion. Sugar  is  rarely  a  cause  of  trouble  in 
nursing  babies.  It  seldom  varies,  ranging 
from  5  to  7  per  cent,  in  the  great  majority  of 
breast-milks.  Young  children,  further,  have  a 
marked  toleration  for  it.  The  proteid  of 
mother's  milk  is  the  most  frequent  cause  of 
nursing  difficulties.  Like  the  fat,  it  may  so  be 
decreased  that  nutritional  disorder  may  be  in- 
duced in  the  patient,  or  it  may  be  very  much 
increased ;  the  latter  being  usually  the  cause  of 
colic  or  constipation  in  otherwise  healthy  nurs- 
ing infants.  In  such  infants  curds  may  be 
found  in  the.  stools,  the  passage  of  which  is 
always  accompanied  by  a  great  deal  of  gas. 
The  milk  may  contain  the  normal  percentage 
of  fat,  sugar,  and  proteid,  but  be  scanty  in 
amount.  Instead  of  the  four  or  five  ounces 
to  which  the  child  is  entitled,  he  may  get  but 
one  or  two  ounces.  Whether  or  not  the  quan- 
tity is  sufficient  can  be  determined  by  weighing 
the  baby  before  and  after  each  nursing,  for 
twenty-four  hours.  One  ounce  of  breast- 
milk  practically  weighs  one  ounce  avoirdupois. 
The  quality  or  strength  is  determined  by  an 
examination  of  the  milk  itself  by  the  physician. 


32  Maternal  Nursing 

Before  nursing,  the  child  is  put  in  the  scales 
without  undressing  him  and  the  weight  noted. 
He  is  allowed  to  nurse  fifteen  minutes.  He  is 
then  removed  from  the  breast  and  weighed. 

Amount  of  milk  required. — A  child  under 
one  week  should  have  gained  from  i  to  2 
ounces;  at  three  weeks  of  age,  2  to  3  ounces; 
four  to  eight  weeks  of  age,  3  to  4  ounces; 
eight  to  sixteen  weeks  of  age,  4  to  6  ounces; 
sixteen  to  twenty- four  weeks  of  age,  6  to  7 
ounces;  six  to  nine  months  of  age,  7  to  8 
ounces;  nine  to  twelve  months  of  age,  8  to  9 
ounces. 

Of  course  arbitrary  limits  cannot  be  fixed 
as  to  the  quality.  Stationary  weight  or  loss 
in  weight  with  a  dissatisfied  child  usually 
means  defects  in  quantity  which  are  readily 
proved  by  the  weighing.  To  be  fed  at  the 
breast  may  also  cause  the  child  to  suffer  from 
an  excess  of  good  milk,  in  which  event  there 
will  be  vomiting  or  regurgitation,  usually  asso- 
ciated with  colic.  When  this  overfeeding  con- 
tinues, dilatation  of  the  stomach  develops, 
vomiting  becomes  habitual,  the  child  loses  in 
weight,  and  the  breast-milk  is  said  not  to  agree, 
and  often,  unfortunately,  the  baby  is  weaned. 
This  has  been  the  outcome  in  scores  of  cases. 


Maternal  Nursing  33 

When  there  is  habitual  vomiting  and  colic  in 
a  nursing  baby,  two  things  are  to  be  done — 
the  baby  must  be  weighed  before  and  after 
nursing,  and  the  milk  must  be  examined. 

I  have  repeatedly  treated  children  for  indi- 
gestion who  were  entirely  relieved  by  shorten- 
ing the  nursing  period.  Weighing  the  baby 
at  intervals  of  from  three  to  five  minutes 
and  noting  the  gain  has  shown  that  the  three 
or  four  ounces  which  may  be  the  child's 
stomach  capacity  was  obtained  in  two, 
three,  or  five  minutes,  the  excess  which 
the  child  took  over  this  amount  being  the 
cause  of  his  trouble.  Given  a  free,  full  breast 
and  a  vigorous  nurser,  and  one  ounce  will  be 
taken  in  one  minute.  When  the  nursing 
"gait"  is  established,  a  child  should  be  kept 
up  to  the  schedule.  There  are  few  more 
pernicious  teachings  than  that  a  baby  should 
be  allowed  to  nurse  when  he  wants  to  and  as 
long  as  he  wants  to.  The  idea  that  a  nurs- 
ing infant  will  take  no  more  than  is  good  for 
him  is  the  fruit  of  inexperience.  Recently  a 
mother  consulted  me  in  regard  to  putting  her 
one-month-old  baby  on  the  bottle,  as  he  had 
many  green  stools,  cried  a  great  part  of  his 
waking  hours,  and  weighed  but  a  few  ounces 


34  Maternal  Nursing 

more  than  at  birth.  Her  milk  was  supposed 
to  be  "too  strong"  for  the  child.  An  examina- 
tion of  the  breast  and  a  talk  with  the  mother 
satisfied  me  that  the  breast-milk  was  not  at 
fault.  An  examination  of  the  milk  proved 
it  to  be  good  average  milk — 3.5  per  cent,  fat, 
6  per  cent,  sugar,  1.45  per  cent,  proteid.  A 
one-day's  test  by  weighing  was  decided  upon. 
He  was  allowed  to  nurse  one  minute  and  rest 
one  minute.  During  the  resting  period  he  was 
weighed.  Weighing  and  resting  him  in  this 
way,  it  was  found  that  in  three  minutes  he  got 
from  3  to  3^2  ounces  of  milk.  The  nursing 
was  then  reduced  to  three  minutes  on  one 
breast  and  five  minutes  on  the  other,  which 
was  the  "slower"  breast  of  the  two.  Every 
sign  of  indigestion  promptly  disappeared 
after  this  change.  The  stools  became  normal 
and  the  infant  made  a  satisfactory  gain  in 
weight  of  one  ounce  daily. 

Necessity  for  milk  examination. — The  quan- 
tity may  be  suitable  for  the  age  of  the  child, 
he  may  not  vomit  or  show  a  sign  of  indiges- 
tion, and  yet  he  may  not  thrive.  In  such  a  case 
an  examination  or  repeated  examinations  of 
the  milk  at  intervals  of  two  or  three  days  will 
usually  show  that  it  is  poor,  below  the  normal 


Maternal  Nursing  35 

perhaps  in  both  fat  and  proteid.  Such  a  case 
occurred  in  the  New  York  Infant  Asylum.  A 
Swedish  woman  was  admitted  with  an  infant 
two  months  old  in  fair  condition.  She  had 
an  abundance  of  milk  and  asked  for  a  foster- 
child,  so  great  was  her  discomfort  from  the 
excessive  flow  of  milk.  The  weekly  weighings 
of  the  children  soon  revealed  that  there  was  no 
growth,  and  both  children  upon  examination 
showed,  after  a  few  weeks,  developing  rickets. 
The  milk  was  then  examined  and  was  found 
deficient  in  all  its  constituents. 

Signs  of  insufficient  nursing. — The  baby 
remains  long  at  the  breast,  perhaps  one-half  to 
three-quarters  of  an  hour.  When  removed, 
he  is  restless  and  uncomfortable.  After  a 
short  time,  in  an  hour  or  less,  he  is  very  hun- 
gry and  demands  frequent  nursings  day  and 
night. 

Management  of  abnormal  milk  conditions. — 
When  it  is  found  that  the  breast-milk  is  too 
strong  or  too  weak,  or  when  the  normal  ratio 
of  fat,  sugar,  and  proteid  are  not  maintained, 
it  may  be  possible  to  increase  or  diminish  the 
milk  strength.  It  may  also  be  possible  to  in- 
crease either  the  fat  or  the  proteid  when 
desirable.  The  heavy  milk  will  usually  be 


36  Maternal  Nursing 

found  in  mothers  who  are  robust,  who  eat 
heartily,  and  who  take  but  little  exercise.  In 
such  a  mother,  the  prescribing  of  a  plain  diet, 
allowing  red  meat  but  once  a  day,  discontinu- 
ing the  malt  liquors  or  wine — which  it  will 
often  be  found  that  she  is  taking, — and  direct- 
ing that  she  walk  a  mile  or  two  a  day,  will 
frequently  bring  the  milk  to  digestible  pro- 
portions. In  some  cases,  however,  this  will 
not  be  successful,  and  the  colic,  constipation, 
and  vomiting  continue,  even  though  the  quan- 
tity obtained  at  each  nursing  is  within  normal 
limits.  In  some  mothers  it  will  be  impossible 
to  change  the  mode  of  life,  except  perhaps  as 
to  the  discontinuance  of  alcohol.  When  such 
conditions  prevail,  the  mother's  milk  may  be 
modified  by  giving  from  one-half  to  one  ounce 
of  boiled  water  or  plain  barley-water  before 
each  nursing.  This  is  a  procedure  to  which 
I  frequently  resort.  One  teaspoonful  of  lime- 
water  added  to  one  ounce  of  water  before  each 
nursing  has  made  the  breast-milk  agree  when 
otherwise  it  would  have  been  impossible. 
When  the  milk  is  deficient  both  in  fat  and 
proteid,  a  diet  composed  largely  of  red  meat, 
poultry,  fish,  rye,  bread,  or  whole-wheat 
bread,  oatmeal,  cornmeal,  with  two  or  three 


Maternal  Nursing  37 

pints  of  milk  daily,  will  often  bring  the  milk 
to  the  normal  requirements.  The  use  of  alco- 
hol in  moderate  amounts,  in  the  form  of  malt 
liquors  or  wine,  will  usually  increase  the  fat. 
I  have  frequently  seen  it  advance  2  per  cent, 
in  from  two  to  three  days.  Disappointments 
in  improving  the  quantity  or  quality  of  the 
breast-milk,  however,  are  frequent. 

In  addition  to  the  one  bottle  which,  for 
reasons  above  mentioned,  is  given  early  in  the 
child's  life,  I  find  it  necessary  at  the  seventh 
month  to  add  an  extra  bottle  or  two.  Usually 
at  this  time  the  proteid  in  human  milk  begins 
to  diminish  in  quantity,  and  as  this  is  the  most 
important  nutritional  element,  an  insufficient 
quantity  at  this  rapidly  growing  period  of  life 
is  a  matter  of  no  little  importance.  At  the 
twelfth  month,  with  very  few  exceptions,  my 
nursing  babies  are  weaned  from  necessity.  At 
this  age  exclusive  nursings,  if  one  considers 
the  best  interests  of  the  child,  are  practically 
out  of  the  question.  .  Out  of  many  thousands 
of  mothers  I  recall  but  one  instance  where  a 
mother  was  able  successfully  to  nurse  her  child 
after  the  twelfth  month.  This  remarkable 
woman,  the  mother  of  six  children,  had  nursed 
every  one  of  them  exclusively  and  successfully 


38  Maternal  Nursing 

up  to  the  fifteenth  or  the  eighteenth  month. 
Mixed  feeding. — With  a  diminution  in  the 
amount  of  milk  secreted,  the  breast  milk  must, 
of  course,  be  supplemented  by  modified  cow's 
milk.  This  method  of  feeding  is  usually  suc- 
cessful. If  the  mother  of  a  six-months-old 
baby  can  satisfactorily  nurse  him  three  times 
in  twenty-four  hours,  he  is  given,  in  addition, 
three  bottle-feedings  in  the  twenty-four  hours, 
in  this  way  supplementing  the  mother's  milk, 
or  the  following  method  may  be  employed. 
Weigh  the  baby  without  undressing  before 
placing  him  to  the  breast  and  again  when  the 
breast  is  empty,  by  this  means  the  amount  ob- 
tained is  readily  learned  and  a  supplementary 
feeding,  one  or  two  or  more  ounces,  may  be 
given  by  bottles  to  supply  the  amount  required. 
The  modified  milk  strength  should  be  that 
which  is  suitable  for  the  average  child  of  his 
age.  (See  Infant  Feeding,  page  65.)  In  be- 
ginning the  use  of  cow's  milk,  however,  it  must 
be  remembered  that  at  first  a  weaker  strength 
must  be  used  than  the  child  will  require  for 
growth,  this  weaker  food  being  necessary  in 
order  gradually  to  accustom  him  to  the  change 
of  food.  If  too  strong  a  cow's-milk  mixture 
is  given  at  first,  it  will  be  very  apt  to  disagree, 


Maternal  Nursing  39 

causing  colic  and  vomiting.  Later,  when  the 
child  has  become  accustomed  to  the  new  food, 
a  stronger  mixture  may  be  given.  When  a 
mother  cannot  give  her  infant  at  least  two  satis- 
factory breast-feedings  daily,  it  is  better  to 
wean  the  child. 

Maternal  conditions  under  which  nursing  is 
•forbidden. — When  the  mother  has  tubercu- 
losis in  any  of  its  various  forms  or  manifes- 
tations, whether  it ,  involves  the  glands,  the 
joints,  or  the  lungs,  breast-feeding  is  to  be  for- 
bidden. In  epilepsy  and  syphilis  nursing  is 
likewise  forbidden.  In  nephritis  and  malig- 
nant disease  of  any  nature,  and  in  chorea,  nurs- 
ing should  be  discontinued.  Women  who  are 
rapidly  losing  weight  should  not  continue 
nursing  their  infants.  In  case  of  serious  ill- 
ness of  any  nature,  such  as  typhoid  fever, 
pneumonia,  or  diphtheria,  and  upon  the  advent 
of  pregnancy,  nursing  should  be  stopped. 

Conditions  which  may  temporarily  produce 
an  unfavorable  effect  upon  the  breast-milk, 
but  not  necessitate  the  discontinuance  of  nurs- 
ing.— The  advent  of  the  first  menstruation 
period  particularly,  and  in  some  cases  of  every 
menstruation  period,  is  attended  with  an  at- 
tack of  colic  or  indigestion  on  the  part  of  the 


40  Maternal  Nursing 

child,  rarely  sufficient,  however,  to  necessitate 
the  discontinuance  of  the  nursing  even  for  a 
single  day. 

Factors  influencing  the  mental  conditions 
of  the  mother,  such  as  anger,  fright,  worry, 
shock,  distress,  sorrow,  or  the  witnessing  of 
an  accident,  may  affect  the  milk  secretion  suffi- 
ciently to  cause  no  little  discomfort  to  the  child, 
and  oftentimes  the  temporary  lessening  of  the 
flow  for  a  day  or  two.  The  influence  of  the 
mental  state  upon  the  character  of  the  milk 
was  early  brought  to  my  attention  while  resi- 
dent physician  at  the  Country  Branch  of  the 
New  York  Infant  Asylum.  In  this  institution 
there  were  usually  about  two  hundred  nursing 
mothers,  the  majority  of  them  from  the  lower 
walks  of  life,  at  least  95  per  cent,  of  the  in- 
fants being  illegitimate.  The  necessity  of 
placing  a  considerable  number  of  these  mothers 
in  wards,  and  their  living  thus  in  close  contact, 
gave  rise  to  rather  frequent  disputes,  and  not 
infrequently  to  fistic  encounters  of  a  decidedly 
vigorous  character.  After  a  particularly  active 
disturbance,  several  nursing  infants  in  the  ward 
would  be  taken  suddenly  ill,  usually  with 
vomiting,  diarrhoea,  and  fever.  When  two 
or  more  infants  were  thus  discovered  ill,  we 


Maternal  Nursing  41 

soon  learned  to  know  the  cause  when  inquiry 
or  evidence  furnished  by  hasty  inspection  of 
the  mother  showed  that  she  had  been  particu- 
larly active  in  the  affair.  A  small  proportion 
of  the  mothers  were  from  the  better  walks  of 
life.  Letters  of  forgiveness  or  reproach  or 
visits  of  a  like  nature  from  fathers,  mothers, 
or  sisters,  have  brought  many  a  sick  baby  to 
my  attention  and  caused  me  many  anxious 
moments. 

Conditions  which  call  for  temporary  discon- 
tinuance of  nursing. — During  an  acute  illness 
with  fever,  such  as  indigestion,  tonsillitis,  and 
minor  illness  of  like  nature,  nursing  should 
be  discontinued  for  a  day  or  two.  When  the 
infant  is  removed  from  the  breast,  it  should 
be  our  effort  to  maintain  the  flow  of  milk. 
This  is  best  done  by  emptying  the  breast  with 
a  breast-pump  (page  49)  at  the  usual  nursing 
period  until  the  time  arrives  when  the  nursing 
may  be  resumed.  In  such  conditions  the  ad- 
vantage of  having  the  baby  accustomed  to  one 
bottle  a  day  will  at  once  be  appreciated. 

Care  of  the  nipples. — Six  hours  after  de- 
livery or  confinement,  the  nipples  should  be 
washed  with  a  saturated  solution  of  boric 
acid  and  the  child  put  to  the  breast  and  nurs- 


42  Maternal  Nursing 


ing  attempted.  After  this,  the  attempts  at 
nursing  should  be  repeated 
every  four  hours,  although 
the  milk  does  not  appear 
in  the  breasts  until  from 
forty-eight  to  seventy-two 
hours  after  the  birth  of  the 
child.  Colostrum  may  be 
present,  which  is  useful  as 
a  laxative  and  may  satisfy 
the  child.  A  further  ad- 
vantage of  the  nursing  at 
FIG.  2.  NIPPLE-SHIELD  this  time  is  that  it  grad- 
ually accustoms  both  the 
nipple  and  the  infant  to  what  will  be  required 
of  them  later.  Immediately  after  the  nurs- 
ing the  nipple  should  be  carefully  washed 
with  a  saturated  solution  of  boric  acid  and 
thoroughly  but  gently  dried.  A  baby  should 
never  be  allowed  to  nurse  on  a  cracked  or  fis- 
sured nipple.  For  this  very  painful  condition 
a  nipple-shield  (Fig.  2)  should  always  be  used. 
Giving  of  water. — From  one-half  to  one 
ounce  of  a  i  per  cent,  solution  of  milk-sugar 
should  be  given  the  infant  every  two  hours 
until  the  milk  appears  in  the  breast.  Other- 
wise there  will  be  unnecessary  loss  in  weight 


The  Wet-Nurse  43 

and  perhaps  a  high  degree  of  fever  due  to  in- 
anition. 

If  the  child  is  restless  and  uncomfortable, 
it  is  safe  to  conclude  that  he  is  thirsty,  and 
one  ounce  of  the  sugar-water  will  usually 
satisfy  him.  With  the  commencement  of 
nursing,  accustom  the  baby  to  getting  his  food 
at  regular  intervals. 

Frequency  of  nursings. — The  new-born 
infant  is  entitled  to  seven  nursings  in  twenty- 
four  hours.  From  6  A.M.  to  10  P.M.,  inclu- 
sive, there  should  be  six  nursings.  There  may 
be  one  nursing  at  2  or  3  A.M.  As  the  child 
becomes  older  less  frequent  nursings  are  re- 
quired. The  following  table  will  be  found 
useful  in  this  connection : 

Fifth  to  the  twelfth  month 5  nursings. 

Third  to  the  fifth  month 6      " 

Third  day  to  the  twelfth  week 7      " 

THE  WET-NURSE 

We  are  called  upon  to  select  a  wet-nurse 
under  various  conditions.  In  a  few  families, 
particularly  in  those  who  have  had  disastrous 
feeding  experiences,  we  are  asked  that  no  at- 
tempts at  artificial  feeding  be  made,  but  that 


44  The  Wet-Nurse 

a  \vet-nurse  be  engaged  in  advance  of  the  con- 
finement so  as  to  be  ready  when  the  time  for 
her  services  arrives.  Usually,  however,  our 
minds  turn  to  the  wet-nurse  when  nutrition 
by  other  methods  is  a  failure.  It  is  well  to 
remember  in  this  connection  that  it  is  not  wise 
to  postpone  our  resort  to  the  wet-nurse  too 
long — until  every  chance  of  her  being  of  as- 
sistance has  passed.  It  may  take  a  few  days' 
observation  or  but  a  single  glance  at  one  of 
these  difficult  feeding  cases  for  us  to  decide 
whether  a  wet-nurse  must  be  secured.  Certain 
it  is  that  in  a  few  cases  we  cannot  do  without 
them.  I  see  perhaps  two  or  three  cases  a  year, 
usually  in  consultation,  in  which  I  insist  that 
further  attempts  at  artificial  feeding  be  discon- 
tinued because  of  the  reduced  condition  of  the 
patient. 

Age  of  the  wet-nurse. — In  the  selection  of  a 
wet-nurse  the  age  during  which  nursing  is 
most  successfully  carried  on  is  to  be  remem- 
bered. Other  things  being  equal,  a  wet-nurse 
should  not  be  under  twenty-two  or  over  thirty- 
five  years  of  age.  The  peasant  woman  of  the 
continent  of  Europe  make  the  best  wet-nurses. 

Type  of  woman  required. — A  woman  should 
not  be  selected  as  a  wet-nurse  without  a  thor- 


The  Wet-Nurse  45 

ough  examination  both  of  herself  and  of  her 
infant.  She  must  be  free  from  skin  diseases, 
tuberculosis,  and  syphilis.  Whether  she  is 
stout  or  thin,  tall  or  short,  amounts  to  little. 
Neither  can  we  place  much  reliance  on  the 
size  of  her  breasts.  Although  full,  firm 
breasts  and  prominent  nipples  are  desirable, 
the  best  indication  as  to  her  nursing  ability  is 
the  condition  of  her  baby.  For  this  reason  it 
is  best  not  to  select  a  woman  before  her  baby 
is  four  weeks  old,  for  by  that  time  his  physi- 
cal condition  will  indicate  with  considerable 
accuracy  the  kind  of  food  he  has  been  getting. 
The  age  of  the  wet-nurse's  milk  need  not  corre- 
spond with  the  age  of  the  patient  for  whom 
she  is  engaged.  As  far  as  age  is  concerned,  a 
breast-milk  from  four  weeks  to  three  months 
old  will  answer  for  any  infant. 

The  results  attending  the  first  few  days  of 
wet-nursing  are  often  most  disappointing. 
The  radical  change  which  takes  place  in  the 
nurses's  habits  of  life,  the  leaving  of  her  own 
child  to  the  care  of  others,  sometimes  pro- 
duces nervous  conditions  which  may  have  a 
decidedly  unfavorable  influence  upon  her  milk. 
So  before  arriving  at  the  conclusion  that  she 
will  not  answer  in  a  given  case,  she  should  have 


46  The  Wet-Nurse 

time  to  adjust  herself  to  the  changed  condi- 
tions. 

Diet  of  the  wet-nurse. — Many  a  good  wet- 
nurse  has  been  ruined,  so  far  as  her  usefulness 
as  a  milk-producer  is  concerned,  by  over- 
indulgence at  the  table.  She  has  been  accus- 
tomed to  a  very  plain  diet  and  some  work, 
which  necessarily  means  exercise.  Upon  as- 
suming her  new  office  she  is  temporarily  the 
most  important  member  of  the  household, 
next  to  the  baby,  and  articles  of  food  are  sup- 
plied to  which  she  is  entirely  unaccustomed 
and  of  which  she  eats  plentifully.  The  result 
is  an  attack  of  indigestion  with  fever,  the  baby 
is  made  ill,  and  the  usefulness  of  the  wet-nurse 
in  the  family  ceases.  These  women  usually 
do  best  upon  a  plain  diet  of  meat,  poultry,  fish, 
vegetables,  cereals,  and  milk.  If  they  are  ac- 
customed to  taking  beer,  one  bottle  daily  may 
be  permitted.  Coffee  may  be  allowed  to  the 
extent  of  one  cup  daily,  and  of  tea  not  more 
than  two  cups  should  be  allowed. 

The  bowel  function. — Women  of  this  class 
are  almost  invariably  neglectful  of  the  bowel 
function,  so  that  this  must  be  attended  to. 
One  free  evacuation  should  take  place  daily. 
As  a  rule,  the  wet-nurse  has  been  accustomed 


The  Wet-Nurse  47 

to  work  and  will  be  more  contented  and  happy 
when  her  time  is  occupied.  Being  out-of- 
doors  from  three  to  four  hours  a  day  is  of 
decided  advantage  to  every  nursing  woman. 
If  she  possesses  sufficient  intelligence  to  take 
the  baby  for  his  outings,  she  should  be  allowed 
to  do  so.  For  the  comfort  of  the  family,  it 
is  wise  not  to  let  a  wet-nurse  know  her  full 
value.  When  she  feels  that  she  is  indispen- 
sable, trouble  is  apt  to  follow  from  one  source 
or  another. 

One  bottle  daily. — It  is  particularly  neces- 
sary, therefore,  that  babies  that  are  wet- 
nursed  should  be  given  one  bottle-feeding 
daily  as  soon  as  they  are  able  to  take  care  of 
it.  The  wet-nurse  will  then  realize  that  she 
can  be  dispensed  with  in  case  of  misconduct, 
or  if  she  leaves  at  an  hour's  notice  the  child 
can  be  given  the  bottle  until  another  nurse  is 
secured.  In  the  great  majority  of  my  cases  it 
has  not  been  necessary  to  continue  the  wet- 
nursing  after  the  children  are  seven  months 
of  age,  for  by  this  time  they  can  usually  be 
fed  on  the  bottle.  Of  course,  unless  her  nurs- 
ing proves  unsatisfactory,  a  wet-nurse  should 
not  be  dismissed  at  the  commencement  of  or 
during  the  summer. 


48  Care  of  the  Breasts  and  Nipples 

CARE  OF  THE  BREASTS  AND 
NIPPLES 

After  nursing  is  well  established  the  baby 
should  be  nursed  at  three  hour  intervals  dur- 
ing the  day.  If  he  sleeps  betwen  10  P.M. 
and  6  A.M.  do  not  wake  him.  One  feeding  at 
2.30  A.M.  is  required  by  a  few  children  up  to 
the  third  month;  the  great  majority,  however, 
do  better  without  it.  Before  and  after  each 
nursing  the  mother's  nipples  should  be  gently 
washed  with  a  saturated  solution  of  boracic 
acid,  using  either  clean  old  linen  or  absorbent 
cotton.  The  nipples  should  be  thoroughly 
dried  after  the  washing. 

Cracked  and  fissured  nipples. — Nursing 
is  often  most  painful  on  account  of  cracks 
and  fissures  in  the  nipples.  These  are  very 
apt  to  occur  if  the  parts  are  neglected,  and 
the  resulting  pain  when  the  child  nurses  is 
unbearable,  necessitating  sometimes  the  dis- 
continuance of  the  breast-feeding.  The  baby 
should  never  be  allowed  to  touch  a  cracked 
or  fissured  nipple,  and  a  nipple-shield  (see 
Fig.  2)  should  be  used  until  the  parts  are 
healed.  Some  babies  take  very  kindly  to  the 
nipple-shield,  and  often  a  great  deal  of  patience 


Care  of  the  Breasts  and  Nipples  49 


must  be  exercised  before  they  can  be  taught 
its  use.  If  the  shield  suggested  does  not  an- 
swer, others  may  be  tried.  The  breast  should 
never  be  allowed  to  become  hard  or  painful. 
If  the  child  does  not  take 
enough  to  keep  the  breasts 
soft  a  breast-pump  should 
be  used  to  remove  the  re- 
mainder. For  this  pur- 
pose, the  so-called  Eng- 
lish breast-pump  (see  Fig. 
3)  is  the  best.  With  the 
first  rush  of  milk  to  the 
breast  it  is  often  very  dif- 
ficult to  prevent  hard, 
painful  nodules  from 
forming  in  the  glands. 
The  free  use  of  the 
breast-pump  and  massage 

with  warm  oil,  if  proper-  we.  3-  ENGLISH  BREAST- 
,  .   ,  :1t   r  PUMP 

ly  carried  out,   will  pre- 
vent the  formation  of  an  abscess. 

When  the  breasts  are  large  and  pendulous, 
a  support  consisting  of  a  bandage  firmly  ap- 
plied around  the  chest  will  often  afford  much 
comfort  and  prevent  serious  trouble.  In  addi- 
tion to  the  use  of  the  nipple-shield,  the  cracked 


5°  Weaning 

nipple  should  be  washed  with  a  saturated 
boracic-acid  solution  after  each  nursing,  and 
dried,  when  a  soothing  ointment  may  be  ap- 
plied on  old  linen ;  such  an  ointment,  composed 
of  ichthyol  fifteen  grains,  vaseline  one-half 
ounce,  oxide-of-zinc  ointment  one-half  ounce, 
has  given  most  satisfactory  results.  The  oint- 
ment should  be  carefully  removed  with  warm 
sweet-oil  and  the  nipple  washed  in  alcohol  be- 
fore the  next  nursing.  When  the  fissures  are 
healed,  the  nursing  may  be  resumed,  allowing 
the  child  for  a  few  days  to  take  the  nipple 
every  second  or  third  nursing,  thus  gradually 
accustoming  the  nipples  to  the  rough  usage. 

WEANING 

When  is  the  nursing  baby  to  be  given  other 
food,  or  how  long  can  the  breast  be  relied 
upon  to  furnish  the  child  its  sole  nourishment  ? 
If  the  mother,  unassisted,  is  able  to  nourish 
her  infant  completely  until  it  is  seven  months 
of  age,  she  is  doing  remarkably  well.  There 
are  very  few  nursing  mothers  who  can  pass 
that  period  without  assistance.  Perhaps  one 
or  two  bottle-feedings  a  day  may  suffice.  In 
many  cases  the  milk  will  fail  about  the  seventh 


Weaning  51 

month,  and  absolute  weaning  be  necessary. 
Granting,  however,  that  the  child  is  thriving 
on  the  breast  alone,  or  doing  satisfactorily  on 
the  breast  with  only  two  daily  feedings,  at  what 
age  should  the  weaning  take  place?  I  have 
known  just  one  mother  out  of  several  thousand 
who  could  nurse  her  child  to  the  child's  advan- 
tage after  twelve  months  had  passed.  I  have 
seen  many  pronounced  cases  of  malnutrition 
and  rickets  due  directly  to  prolonged  nursing. 
Indigestion  and  diarrhoea  are  often  the  out- 
come of  prolonged  breast-feeding. 

The  weaning  in  health  should  begin  not 
later  than  the  twelfth  month,  and  in  many  in- 
stances it  would  be  to  the  advantage  of  the 
child  if  nursing  was  interrupted  earlier.  It  is 
best  accomplished  gradually  by  substituting 
bottle-feeding  for  nursing,  giving  only  one 
bottle  the  first  day,  two  the  second,  three  the 
third,  and  so  on  until  in  a  week  or  ten  days 
weaning  is  complete.  In  case  the  child  is  ill 
we  may  be  obliged  to  wean  at  once,  when 
bottle-feeding  is  substituted  for  the  breast,  but 
the  milk  formula  corresponding  to  his  age 
should  not  be  given.  To  a  child  six  months  of 
age  give  the  three-months'  formula;  a  child 
nine  months  of  age  should  receive  the  six- 


52  Weaning 

months'  formula.  A  gradual  increase  to  the 
formula  suggested  for  a  child  the  age  of  the 
patient  may  be  made  if  all  goes  well.  After 
the  ninth  month  it  is  often  possible  to  feed 
from  a  cup,  which  is  then  to  be  preferred  to 
bottle-feeding  as  a  substitute  for  the  breast. 
It  is  best  not  to  attempt  weaning  during  the 
hot  months  unless  the  conditions  demanding 
it  are  urgent. 

Care  of  breasts  during  weaning. — When 
the  breast-feeding  is  carried  on  the  usual 
length  of  time — from  nine  to  twelve  months, 
— the  process  of  weaning  ordinarily  causes 
little  or  no  discomfort.  All  that  is  usually 
required  is  to  press  out  enough  of  the  milk  to 
relieve  the  patient  as  often  as  the  breast  be- 
comes painful,  which  may  not  be  more  than 
two  or  three  times  a  day.  When  the  weaning 
is  necessarily  abrupt,  no  little  discomfort  may 
result.  If  there  is  a  free  flow  of  milk,  which 
is  apt  to  be  the  case  when  the  weaning  must 
take  place  in  the  early  nursing  period,  tightly 
bandaging  the  breasts  is  required.  When 
localized  hardened  areas  occur  in  the  glands, 
they  should  be  massaged  until  softened,  and 
the  bandage  reapplied  and  worn  until  the 
secretion  ceases.  When  the  weaning  can  more 


The  Selection  of  Milk        53 

gradually  be  done,  the  best  way  is  to  give  one 
less  nursing  every  second  or  third  day  until 
only  two  are  given.  After  this  has  been  prac- 
tised for  one  week,  these  also  can  be  discon- 
tinued. In  cases  where  sudden  weaning  is 
required,  a  saline  laxative,  such  as  citrate  of 
magnesia  or  Rochelle  salts,  should  be  given 
every  day  for  five  days — sufficient  to  produce 
two  or  three  watery  evacuations  daily.  In  the 
meantime  the  mother  should  abstain  from 
fluids  of  all  kinds  up  to  the  point  of  positive 
discomfort. 

THE  SELECTION  OF  MILK 

The  selection  of  the  milk  on  which  the  baby 
is  to  live  is  a  matter  of  no  little  importance. 
There  is  a  vast  difference  in  the  quality  and 
cleanliness  of  the  milks  on  the  market.  Too 
many  mothers  look  upon  all  milk  as  being  of 
uniform  value  because  it  all  has  a  similar  ap- 
pearance. While  the  general  character  of  the 
milk  sold  has  improved  greatly  as  regards 
cleanliness  during  the  past  few  years,  a  great 
deal  of  that  used  at  the  present  time  is  unfit 
for  food  for  a  baby. 

Certified   milk. — New   York   City   mothers 


54        The  Selection  of  Milk 

should  insist  that  the  milk  used  be  bottled  and 
sealed  at  the  farm,  and  also  insist  that  it  be 
certified  by  the  New  York  Milk  Commission. 
Milk  if  properly  produced  is  expensive.  The 
most  expensive  milk  will,  as  a  rule,  be  found 
safest  for  use. 

Necessary  precautions.  —  When  certified 
milk  or  one  of  the  higher-class  milks  is  not 
obtainable,  as  is  the  case  with  those  whose 
home  is  in  the  country,  and  for  the  families 
from  the  larger  cities  who  spend  the  summer 
months  in  more  or  less  remote  country 
districts,  the  matter  of  securing  a  safe  milk  is 
of  vital  importance.  The  average  farmer  is 
notoriously  careless  in  the  handling  of  milk, 
and  in  the  country  districts,  where  the  milk 
supply  should  be  the  best,  it  is  often  as  bad  as 
can  well  be  imagined.  In  the  country,  where 
the  milk  is  furnished  by  the  farmer  direct,  a 
special  arrangement  may  be  made,  by  which 
he  agrees :  that  the  cow's  belly,  udder,  and 
teats  shall  be  wiped  off  with  a  damp  cloth  be- 
fore milking;  that  the  milker's  hands  shall  be 
washed  before  milking;  that  the  few  jets  of 
the  fore-milk  shall  be  thrown  away;  and  that 
as  soon  as  the  milk  is  drawn  it  shall  be  strained 
through  absorbent  cotton  into  a  quart  milk 


The  Selection  of  Milk        55 

bottle,  suitably  corked,  and  placed  in  a  pail 
of  cracked  ice.  The  cracked  ice  and  the  ab- 
sorbent cotton,  are,  of  course,  furnished  by 
the  consumer.  For  the  extra  trouble  the 
farmer  receives  from  fifteen  to  twenty-five 
cents  a  quart  for  the  milk.  The  improved 
milk-pail  with  the  small  top  opening  insures 
a  much  cleaner  milk,  as  it  offers  much  less 
opportunity  for  droppings  to  fall  into  it  dur- 
ing the  milking. 

For  those  who  have  country  homes  and 
who  can  control  their  milk-supply,  the  above 
precautions  may  be  carried  out  to  the  letter. 
By  such  careful  control  of  the  home  product, 
and  by  the  use  of  milk  from  those  dairies  only 
which  observe  the  above  precautions,  the  acute 
digestive  disorders  of  summer  among  my 
patients  are  rendered  a  very  unusual  occur- 
rence. These  precautions,  with  the  knowledge 
of  the  mother  or  nurse  as  to  what  to  do  at  the 
first  sign  of  a  digestive  disorder,  will  reduce 
the  number  of  the  so-called  summer  diarrhoea 
cases  to  a  very  insignificant  figure. 

A  further  and  very  essential  requirement 
is  that  all  cows  used  for  furnishing  milk  to 
infants  be  tested  for  tuberculosis  every  six 
months. 


56       Pasteurization  of  Milk 

Care  of  the  milk  after  delivery. — There  is 
very  little  gained  through  the  farmer  produc- 
ing a  clean  safe  milk  and  keeping  the  milk  iced 
until  delivered  if  the  mother  or  nurse  allows  it 
to  stand  in  the  hot  air  of  the  kitchen  and  per- 
haps exposed  to  flies  and  other  insects.  As  soon 
as  received  the  milk  should  be  placed  in  the 
ice-box  on  the  ice,  not  in  the  compartment  be- 
low where  the  vegetables  and  meats  are  kept. 
Here  the  milk  should  rest  until  such  time  in  the 
morning  as  the  mother  is  able  to  devote  her 
attention  to  the  preparation  of  the  food.  When 
the  family  conditions  allow  there  should  be  a 
special  ice-box  for  the  baby's  milk. 

The  nursery  ice-box  should  be  kept  clean 
and  filled  with  ice  and  contain  a  thermometer. 
The  temperature  should  not  be  above  50°. 

STERILIZATION    AND    PASTEURIZA- 
TION OF  MILK 

Sterilized  milk  is  rarely  used  at  the  present 
time  in  routine  feeding.  Milk  is  said  to  be 
sterilised  when  it  has  been  heated  to  the  boil- 
ing point,  212°  F.,  and  kept  at  this  point  for 
thirty  minutes. 

Pasteurised  milk  is  milk  heated  to  I55°F. 


Pasteurization  of  Milk       57 


and  kept  at  this  temperature  for  thirty 
minutes.  In  heating  the  milk  we  have  two 
objects  in  view :  to  kill  the  harmful  micro- 
organisms which  it  may  contain,  and  to  keep 
the  milk  sweet  for  a  longer  time  than  would 


FIG.    4.      FREEMAN    PASTEURIZER    WITH    BOTTLE   RACK 
REMOVED 

otherwise  be  possible.  The  degree  of  heat 
to  which  the  milk  is  subjected  should  depend 
upon  the  season  of  the  year,  the  source  of  the 
supply,  the  age  of  the  milk,  and  the  digestive 
capacity  of  the  child.  The  more  the  milk  is 
heated  the  more  difficult  of  digestion  it  be- 
comes, and  the  more  liable  it  is  to  produce  con- 
stipation; so  that,  other  things  being  equal, 
the  less  we  heat  the  milk  the  better  the  nourish- 


58       Pasteurization  of  Milk 

ment  we  furnish  to  the  child.  In  country  dis- 
tricts where  the  cows  are  known  to  be  healthy, 
and  the  milk  clean  and  fresh,  heating  is  un- 
necessary. In  cities  and  large  towns,  where 
the  source  of  the  milk  may  be  unknown,  and 
where  it  is  from  twenty- four  to  thirty-six 
hours  old  when  it  reaches  the  consumer;  heat- 
ing to  a  moderate  degree  is  a  safe  procedure 
at  any  time  of  the  year.  Pasteurizing  the  milk 
kills  most  of  the  dangerous  germs  without 
materially  affecting  the  digestibility,  or  chang- 
ing the  taste  of  the  milk.  Among  the  intelli- 
gent and  cleanly  I  advise  the  pasteurization  of 
milk;  among  the  ignorant  poor  and  the  care- 
less,— such  as  we  frequently  see  in  out-patient 
work, — the  milk  should  be  boiled,  particularly 
during  the  hot  months.  The  pasteurization  of 
milk  is  best  accomplished  by  the  use  of  the 
Freeman  Pasteurizer  (see  Fig.  4).  Directions 
for  use  are  furnished  with  the  Pasteurizer. 

If  for  any  reason  the  Freeman  Pasteurizer 
cannot  be  used,  the  milk  may  be  heated  in  a 
double  boiler.  If  this  is  not  at  hand  an  ordi- 
nary agate  basin  may  be  used.  The  vessel 
should  be  placed  over  a  slow  fire,  with  a  milk 
thermometer  held  in  the  mixture.  When  the 
thermometer  registers  I7O°F.,  remove  the 


The  Nursing-Bottle  and  Nipple  59 

milk  from  the  fire  and  pour  it  into  as  many 
bottles  as  there  are  feedings  in  the  twenty- 
four  hours.  Absorbent  cotton  should  be  used 
for  stoppers.  The  bottles  should  be  cooled 
rapidly  by  placing  them  in  cold  water.  The 
Freeman  Pasteurizer  should  always  be  used 
if  possible,  for  the  reason  that  it  saves  much 
trouble,  the  temperature  to  which  the  milk  is 
heated  is  uniform,  it  requires  no  manipulation 
of  the  milk  after  it  has  been  prepared  and 
heated,  and  there  are  no  chances  of  the  con- 
tamination of  the  milk  from  the  air. 

THE  NURSING-BOTTLE  AND  NIPPLE 

There  are  two  requirements  that  a  nursing- 
bottle  must  fulfill :  it  must  have  a  capacity  suffi- 
cient for  one  full  feeding,  and  it  must  be  so 
constructed  as  to  be  readily  cleansed.  The 
oval  bottle  (Fig.  5)  with  rounded  edges  an- 
swers best.  These  may  be  obtained  in  sizes 
of  from  three  to  nine  ounces.  As  many  bottles 
are  needed  as  there  are  feedings  in  twenty-four 
hours.  When  the  bottle  is  emptied  it  should  be 
rinsed  and  filled  with  cold  water.  Each  morn- 
ing before  starting  formula,  wash  all  the  bottles 
and  articles  to  be  used  with  a  stiff  brush  and 


60  Artificial  Feeding 


plenty  of  hot  water  and  a  pure  soap.  Then 
rinse  and  boil  15  minutes.  Boil  articles  every 
day.  The  straight,  black  nipple 
(Fig.  5)  is  also  preferred,  for 
the  reason  that  it  can  be  turned 
inside  out  and  easily  cleansed. 
A  nipple  which  cannot  be  turned 
should  never  be  used.  After  us- 
ing, a  nipple  should  be  turned 
and  scrubbed  with  a  stiff  brush 
and  borax  water — a  tablespoon- 
ful  of  borax  to  a  pint  of  water. 
When  not  in  use,  the  nipple 
should  be  kept  in  borax  water. 
Before  placing  it  on  the  bottle  it 
should  be  rinsed  in  boiled  water. 
The  nipples  should  be  boiled 
FIG  5  NURS-  once  a  day.  The  blind  nipples — 
ING  BOTTLE  AND  those  without  holes — are  the 
best.  Holes  of  the  required  size 
may  be  made  with  a  red-hot  cambric  needle. 

ARTIFICIAL  FEEDING 
BOTTLE-FEEDING 

When  it  is  decided  that  the  child  will  have 
to  be  nourished  by  other  means  than  the  breast, 
we  are  obliged  to  furnish  a  suitable  substitute 


Artificial  Feeding  61 

for  the  mother's  milk  which  the  child  has  a 
right  to  demand.  In  our  selection  we  must 
be  guided  by  Nature  and  furnish  a  food  that 
will  correspond  as  closely  as  possible  to  the 
mother's  milk.  This  can  be  done  only  by  the 
use  of  cows'  milk  properly  prepared  and 
diluted.  Cows'  milk  differs  from  mother's 
milk  in  its  most  important  constituents.  Good 
cows'  milk  contains  primarily  3.50  to  4  per 
cent,  of  -fat,  3.50  to  4  per  cent,  of  proteid,  and 
4  to  5  per  cent,  of  sugar.  Mother's  milk  on 
the  other  hand  contains  3.5  to  4  per  cent,  of 
fat,  1.5  per  cent,  of  proteid,  and  7  per  cent,  of 
sugar.  It  will  be  seen  that  cows'  milk  con- 
tains more  proteid  (curd)  and  less  sugar  than 
is  contained  in  mother's  milk.  We  must  en- 
deavor to  make  the  proportion  of  the  important 
constituents  of  cows'  milk — the  fat,  proteid, 
and  sugar — correspond  to  that  of  mother's 
milk.  This  has  given  rise  to  the  term  modified 
milk.  Cows'  milk  is  made  to  correspond  to 
that  of  the  mother  by  diluting  it  with  water 
to  reduce  the  proteid,  and  then  by  adding  cream 
and  milk-sugar  to  bring  up  the  fat  and  sugar 
to  the  required  strength. 

The  term  modified  milk  is  not  a  good  one, 
for  the  term  "modified"   does  not  cover  all 


62  Artificial  Feeding 

that  is  done  in  rendering  cows'  milk  a  suitable 
diet,  that  is,  changing  it  to  correspond  to 
mother's  milk.  We  would  have  very  little  suc- 
cess in  infant  feeding  if  this  were  all  we  did. 
The  milk  must  be  adapted  to  a  child's  age  and 
peculiarities,  so  that  the  term  adapted  milk 
expresses  far  better  what  we  wish  to  accom- 
plish. In  adapting  milk  to  an  infant,  we  must 
remember  that  cows'-milk  proteid  (curd)  is 
more  difficult  to  digest  than  the  proteid  of 
mother's  milk,  and  that  frequently  a  smaller 
amount  of  fat  must  be  given  than  is  contained 
in  mother's  milk.  Particularly  must  these  pre- 
cautions be  observed  in  the  very  young  and 
delicate.  The  gravest  error,  and  one  most  fre- 
quently made  in  cows'-milk  feeding,  is  that  of 
giving  the  food  too  strong,  at  the  beginning. 
In  consequence,  the  digestive  organs  are  over- 
taxed, the  child  vomits,  has  colic,  suffers  from 
constipation  or  diarrhoea,  and,  of  course,  can- 
not thrive;  cows'  milk  is  therefore  discarded 
because  it  did  not  agree  with  the  baby,  while 
it  was  not  the  milk  but  the  way  it  was  given 
that  was  at  fault.  In  the  feeding  formulas 
given  below,  the  milk  is  adapted  to  the  various 
ages  of  infancy  and  not  to  the  child's  condi- 
tion, as  that  would  obviously  be  impossible. 


Artificial  Feeding  63 

These  formulas  will  be  found  suitable  for 
average  infants  in  fair  health.  In  the  matter 
of  feeding,  every  child  is  a  law  unto  himself 
and  he  must  be  fed  individually.  For  some 
babies  the  formulas  suggested  will  not  answer 
at  all.  One  six-months'  child  may  require  the 
nine-months'  formula,  while  another  may  be 
able  to  take  only  the  three-months'  formula. 
All  babies  of  the  same  age  or  weight  must  not 
be  expected  to  thrive  on  food  of  exactly  the 
same  strength. 

It  is  the  duty  of  the  physician  to  adapt  the 
milk  to  the  patient's  digestive  capacity  by  giv- 
ing to  each  the  required  proportion  of  fat, 
proteids,  and  sugar.  The  signs  of  successful 
bottle-feeding  are  the  same  as  of  successful 
breast-feeding:  comfort,  sleep,  and  an  aver- 
age gain  in  weight  of  not  less  than  four  ounces 
a  week.  There  should  be  two  or  three  yellow 
stools  daily. 

Unsuccessful  feeding. — The  signs  of  unsuc- 
cessful feeding  are  vomiting,  discomfort  after 
feeding,  habitual  colic,  green,  undigested 
stools,  and  loss,  or  a  very  slight  gain,  in  weight. 
A  very  few  children  cannot  take  cows'  milk 
in  any  form.  In  this  class  belong  those  who 
have  been  badly  managed.  They  have  taken 


64  Artificial  Feeding 

cows'  milk  too  strong  or  otherwise  improperly 
adapted.  They  may  have  undergone  a  series 
of  hysterical  changes  with  various  proprietary 
meal  foods  in  the  hope  that  something  might 
be  found  which  would  agree  with  them  and  on 
which  they  might  thrive. 

In  some  cases  cows'  milk  of  any  strength 
produces  colic  and  vomiting  or  more  often 
diarrhoea.  These  difficult  feeding  cases, 
whether  the  result  of  the  delicate  or  peculiar 
condition  of  the  child  per  se  or  of  improper 
feeding,  require  the  greatest  patience  on  the 
part  of  the  physician  and  mother.  Many  of 
these  cases  must  be  seen  by  the  physician  every 
day  for  weeks  before  they  can  be  brought  to 
take  a  suitable  diet.  Milk  in  some  must  be 
temporarily  discarded  and  substitutes,  such  as 
whey,  diluted  cream,  barley  water,  broths,  or 
malt  soups,  have  to  be  used.  After  a  short 
time  a  very  small  amount  of  milk  may  be  added 
to  the  substitute  which  has  been  found  best 
to  agree.  Should  the  milk  again  cause  dis- 
turbance, condensed  milk — one-half  to  one 
teaspoon ful — may  be  given  with  barley  water, 
increasing  the  amount  of  condensed  milk  grad- 
ually if  it  is  found  to  agree.  A  wet-nurse  is 
almost  indispensable  in  some  of  these  cases. 


Food  Formulas  for  Well  Babies  65 

FOOD  FORMULAS  FOR  WELL  BABIES 

In  using  cows'  milk  for  infant  feeding  the 
milk  is  allowed  to  stand  in  the  quart  bottle 
on  the  ice  for  five  hours. 

The  top  1 6  ounces  are  then  dipped  off  with 
a  one  ounce  cream  dipper.  (See  Fig.  6.)  If 
a  dipper  is  not  available  the  top  16 
ounces  may  be  carefully  poured  out 
of  the  bottle.  The  poured  off  top  16 
ounces  is  the  milk  used  until  the 
third  month;  after  this  age  larger 
amounts  must  be  poured  or  dipped 
from  the  top. 

The  following  formulas  are  sug- 
gested for  the  various  ages  noted : 


FROM   THE  THIRD  TO  THE  TENTH  DAY 

Milk  (top  16  oz.) 3     ounces 

T  •  .  FIG.  O. 

Lime-water Bounce  THE 

Milk-sugar I      ounce         CHAPIN 

Boiled  water i6y2  ounces 

Seven  feedings  in  twenty-four  hours;  2  to  3, 
ounces  at  three-hour  intervals  during  the  day 
and  four-hour  intervals  at  night. 


66  Food  Formulas  for  Well  Babies 

FROM  THE  TENTH  TO  THE  TWENTY-FIRST  DAY 

Milk  (top  16  oz.) 6     ounces 

Lime-water I  ^  ounces 

Milk-sugar i]/2  ounces 

Boiled  water i6l/2  ounces 

Seven  feedings  in  twenty- four  hours;  2  to  3 
ounces  at  three-hour  intervals  during  the  day 
and  four-hour  intervals  at  night. 

FROM  THE  THIRD  TO  THE  SIXTH  WEEK 

Milk  (top  16  oz.) 10  ounces 

Lime-water 2  ounces 

Milk-sugar 2  ounces 

Boiled  water 20  ounces 

Seven  feedings  in  twenty-four  hours;  3  to  4 
ounces  at  three-hour  intervals  during  the  day 
and  four-hour  intervals  at  night. 

FROM   THE  SIXTH   WEEK  TO  THE  THIRD  MONTH 

Milk  (top  16  oz.) 14  ounces 

Lime-water 3  ounces 

Milk-sugar 2  ounces 

Boiled  water 18  ounces 

Seven  feedings  in  twenty- four  hours;  4  to  5 
ounces  at  three-hour  intervals  during  the  day 
and  four-hour  intervals  at  night. 


Food  Formulas  for  Well  Babies  67 

FROM  THE  THIRD  TO  THE  FIFTH    MONTH 

Milk  (top  18  oz.) 18  ounces 

Lime-water 3  ounces 

Milk-sugar 2  ounces 

Boiled  water 19  ounces 

Six  feedings  in  twenty-four  hours;  5  to  6 
ounces  at  three-hour  intervals  during  the  day 
and  a  feeding  at  10  P.M. 

FROM  THE  FIFTH  TO  THE  SEVENTH   MONTH 

Milk  (top  24  oz.) 24  ounces 

Lime-water 3  ounces 

Milk-sugar 2  ounces 

Boiled  water 15  ounces 

Five  feedings  in  twenty-four  hours;  6  to  7 
ounces  at  four-hour  intervals,  the  last  feeding  at 
10  P.M. 

FROM  THE  SEVENTH  TO  THE  NINTH  MONTH 

Milk  (whole)   28  ounces 

Lime-water 3  ounces 

Milk-sugar 2  ounces 

Barley  water  14  ounces 

Five  feedings  in  twenty- four  hours;  7  to  9 
ounces  at  four-hour  intervals,  the  last  feeding  at 
10  P.M. 


68  Food  Formulas  for  Well  Babies 

FROM  THE  NINTH  TO  THE  TWELFTH   MONTH 

Milk  (whole)   32  ounces 

Lime-water 3  ounces 

Milk-sugar 2  ounces 

Barley  water 10  ounces 

Five  feedings  in  twenty- four  hours ;  8  to  9 
ounces  at  four-hour  intervals,  the  last  feeding  at 
IO  P.M.  Nine  ounces  is  the  maximum  amount  that 
should  be  given  a  baby  at  one  time.  The  feeding 
should  be  continuous.  Re-warming  milk  that  has 
been  kept  in  the  bottle  is  a  very  dangerous 
practice.  If  the  entire  contents  of  the  bottle  are 
not  taken  it  may  mean  that  the  food  is  too  strong, 
or  that  the  interval  between  feedings  needs  to  be 
lengthened.  Twenty  minutes  is  the  usual  time 
allowed  for  taking  the  bottle. 

Whole  milk. — To  obtain  whole  milk  shake 
the  bottle  before  use. 

Barley  water. — Barley  water  is  made  by 
cooking  i  ounce  of  Robinson's  or  Cereo  bar- 
ley flour  in  I  pint  of  water  for  thirty  minutes. 
Boiled  water  is  added  to  replace  the  amount 
lost  in  boiling.  The  barley  water  should  not 
be  hot  when  added  to  the  milk  and  lime-water. 
Milk-sugar  may  be  dissolved  in  hot  barley 
water. 


Food  Formulas  for  Well  Babies  69 

Keep  the  nursing  bottles  on  the  ice  after  they 
are  filled. 

Convenient  feeding  hours  are  6,  10,  2,  6, 
10  P.M.  after  5  months  of  age.  Strong  vigor- 
ous infants  may  require  stronger  food  than 
the  above  after  the  seventh  month. 

Farina  and  cream  of  wheat. — It  is  not  at  all 
unusual  for  me  to  allow  infants  from  the 
seventh  to  the  ninth  month  a  tablespoon ful  or 
two  of  farina  or  cream  of  wheat  jelly  (cooked 
two  hours  in  water)  before  the  10  A.M.  and 
6  P.M.  feedings,  with  an  ounce  or  two  of  the 
milk  formula  over  it. 

Beef  juice  and  dried  bread. — Occasionally 
at  this  age,  2  or  3  teaspoonfuls  of  beef-juice 
mixed  with  bread-crumbs  or  a  level  tablespoon- 
ful  of  carrots,  squash  or  spinach,  are  given 
before  the  2  P.M.  feeding.  A  piece  of  unsweet- 
ened zwieback  or  a  crust  of  dried  bread  may  be 
given  after  the  bottle. 

Orange  juice  may  be  brought  into  use  as 
soon  as  the  4-hour  interval  is  instituted. 

One  hour  before  the  second  feeding  from 
one  to  three  teaspoonfuls  mixed  with  an  equal 
quantity  of  water  may  be  given.  If  the  juice 
is  at  all  tart  a  little  sugar  may  be  added. 

An  advantage  of  the  early  spoon  feeding  of 


70  Food  Formulas  for  Well  Babies 

the  cereals  and  vegetables,  aside  from  its  nutri- 
tional value  rests  in  the  fact  that  the  child 
learns  early  to  take  food  other  than  the  bottle. 

It  will  be  noticed  that  considerable  latitude 
is  allowed  as  to  the  amount  of  food  which  is 
to  be  given  at  one  feeding.  This  is  because 
of  the  difference  in  the  capacity  of  individual 
children.  After  the  third  month  the  midnight 
feeding  should  be  discontinued.  Six  feedings 
will  be  sufficient,  the  first  at  6  A.M.  and  the 
last  at  10  P.M.  Between  10  P.M.  and  6  A.M. 
the  child  should  sleep.  Babies  are  easily 
broken  from  the  night  bottle  by  substituting 
a  bottle  of  boiled  water  or  a  milk  mixture 
greatly  diluted  with  water.  The  child  soon 
discovers  that  this  is  not  worth  waking  for. 
As  a  result  of  a  full  night's  rest  the  digestive 
organs  are  better  able  to  do  their  work,  the 
appetite  is  increased,  and  a  larger  amount  of 
food  may  be  given  at  each  feeding. 

Special  adaptation. — The  foregoing  methods 
will  be  found  useful  for  the  majority  of  aver- 
age well  babies.  Those  with  pronounced  diges- 
tive peculiarities  should  have  the  food  especially 
adapted. 

When  the  milk  does  not  agree  the  cause 
must  be  discovered.  The  food  as  a  whole 


Feeding  after  the  First  Year  71 

may  be  too  strong,  when  there  will  be  indi- 
gestion and  colic,  and  possibly  diarrhoea  and 
vomiting.  If  the  food  contains  too  much 
cream  there  will  be  looseness  of  the  bowels, 
and  colicky  stools,  with  considerable  straining; 
there  is  apt  to  be  regurgitation  also.  An  indi- 
cation of  excess  of  sugar  consists  in  the  eruc- 
tation of  gas  and  a  regurgitation  of  sour, 
watery  material.  Diarrhoea  may  also  be  pro- 
duced by  too  high  sugar.  Excess  of  cows'- 
milk  proteid  (curd)  may  be  the  cause  of 
habitual  colic,  and  is  an  important  element  in 
habitual  constipation.  We  sometimes  see 
children  who  cannot  take  fresh  cows'  milk 
in  any  form.  In  these  the  milk  must  be 
cooked  or  one  of  the  evaporated  milks  given. 

FEEDING  AFTER  THE  FIRST  YEAR 

At  the  completion  of  the  twelfth  month  the 
average  well-regulated  baby  should  be  weaned, 
and  other  nourishment  given.  The  food  suit- 
able for  the  second  year  of  life  and  the  method 
of  its  preparation  and  administration  are  sub- 
jects upon  which  the  masses  are  most  pro- 
foundly ignorant.  A  few  children  at  this 
period  of  life  are  overfed,  and  carelessly  given, 
at  improper  intervals,  unsuitable  food,  wretch- 


72  Feeding  after  the  First  Year 

edly  cooked.  Summer  diarrhoea  finds  its  great- 
est number  of  victims  among  those  children 
over  twelve  months  of  age  who  have  been 
carelessly  fed.  The  dreaded  "second  summer" 
robs  many  homes  because  of  ignorant  or  care- 
less parents.  The  second  summer  managed 
properly  is  hardly  more  dangerous  than  any 
other  summer  during  the  early  years  of  a 
child's  life.  It  is  almost  a  universal  custom 
when  the  child  is  weaned  or  given  something 
other  than  a  milk  diet  to  allow  him  "tastes" 
from  the  table.  Very  often  these  tastes  com- 
prise the  entire  dietary  of  the  adult.  Milk  is 
oftentimes  the  only  suitable  article  of  diet  that 
is  given.  Afterward  not  only  is  the  other  food 
selected  unsuitable,  but  it  is  given  irregularly, 
and  supplemented  by  crackers  kept  on  hand 
for  use  between  meals.  During  the  hot 
months  the  gastro-intestinal  tract  is  less  able 
to  bear  such  abuse  and  the  child  becomes  ill. 
Usually  when  the  twelfth  month  is  completed 
I  give  the  mother  a  diet  schedule,  with  instruc- 
tions to  begin  gradually  with  the  articles  al- 
lowed, in  order  to  test  the  child's  ability  to 
digest  them.  Every  new  article  of  food  should 
be  carefully  prepared  and  given  at  first  in  very 
small  quantities.  All  meals  are  to  be  given 


Feeding  after  the  First  Year  73 

regularly,  with  nothing  between  meals.  With 
many  children  this  expansion  of  the  diet  list 
is  attended  with  considerable  difficulty.  They 
are  thoroughly  satisfied  with  the  milk,  and  re- 
fuse all  other  forms  of  nourishment.  In  such 
cases  time  and  patience  are  necessary  at  the 
feeding  time.  The  more  solid  articles  of  diet 
should  be  given  first,  and  the  milk  kept  in  the 
background. 

Among  the  underfed  seen  at  this  period  of 
life  are  those  who  were  nursed  too  long  or 
those  who  were  kept  for  too  long  a  time  upon 
an  exclusive  milk  diet.  A  great  majority  of 
the  cases  of  malnutrition  of  the  second  year 
are  seen  in  the  exclusively  milk-fed.  They 
are  pale,  soft,  flabby,  badly  nourished  children. 

The  following  is  a  diet  schedule  which  I 
have  employed  for  several  years.  Each  mother 
is  instructed  to  select,  from  the  foods  allowed, 
a  suitable  meal. 

From  the  twelfth  to  the  fifteenth  month:  four 

meals  daily. 

7  A.M.  Two  or  three  tablespoonfuls  of 
cornmeal,  oatmeal,  wheatena,  hominy,  rice  (all 
cooked  four  hours  the  day  before  in  water), 
served  with  butter  or  milk  and  a  little  sugar. 


74  Feeding  after  the  First  Year 

Eight  ounces  milk  from  glass  or  bottle.  Bread 
stuffs. 

9  A.M.  Juice  of  one-half  orange  or  three 
ounces  prune  juice. 

ii  A.M.  One  tablespoonful  of  either  scraped 
steak,  minced  chicken  or  minced  chop,  or  soft 
boiled  egg  mixed  with  bread  crumbs.  Baked 
or  mashed  potato  ( medium  size  ) .  Glass  or  bot- 
tle of  milk.  Bread  stuffs.  Sleep  after  this  meal. 

2  130  P.M.  Eight  ounces  chicken  or  mutton 
broth  with  bread  or  rice  in  it  or  eight  ounces 
milk.  One  tablespoon  stewed  carrots,  squash 
or  spinach  when  broth  is  given.  Desserts : 
Custard,  cornstarch,  junket.  Bread  stuffs. 

6  P.M.  Two  or  three  tablespoon fuls  farina 
or  cream  of  wheat  (cooked  two  hours  in 
water),  or  one  of  above  cereals  served  as  di- 
rected. Eight  ounces  milk  from  glass  or 
bottle.  Bread  stuffs.  Bread  Stuffs:  Wheats- 
worth  biscuit.  Zwieback  or  Holland  Rusk. 
Toast. 

From  the  Fifteenth  to  eighteenth  month:  four 
meals  daily. 

7 130  A.M.  Two  or  three  tablespoonfuls 
cornmeal,  oatmeal,  wheatena,  hominy,  rice  (all 
cooked  four  hours  the  day  before  in  water), 


Feeding  after  the  First  Year  75 

served  with  butter  or  milk,  with  or  without 
sugar.  Glass  of  milk.  Bread  stuffs. 

9  A.M.  Juice  of  one  orange  or  three  ounces 
prune  juice. 

ii  A.M.  One  tablespoonful  scraped  steak, 
minced  chicken,  minced  chop,  soft  boiled  egg 
mixed  with  bread  crumbs.  Baked  or  mashed 
potato.  One  tablespoonful  spinach,  aspara- 
gus, string  beans,  peas,  squash,  stewed  carrots, 
stewed  celery.  Desserts:  Stewed  apples, 
stewed  prunes,  baked  apple.  No  milk  at  this 
meal.  Bread  stuffs.  Sleep  after  this  meal. 

2 130  P.M.  Eight  ounces  of  chicken  or  mut- 
ton broth  with  bread  or  rice  in  it  or  eight 
ounces  milk.  Small  cup  of  custard,  cornstarch, 
or  junket.  Bread  stuffs. 

6  P.M.  Two  or  three  tablespoonfuls  farina 
or  cream  of  wheat  (cooked  two  hours  in 
water)  or  one  of  above  cereals  served  as  di- 
rected. Glass  of  milk.  Bread  Stuffs :  Wheats- 
worth  biscuit.  Zwieback  or  Holland  Rusk. 
Dried  bread.  Plain  white  or  whole  wheat 
bread. 

From  the  eighteenth  month  to  the  third  year: 
three  meals  daily. 

7:30  A.M.  Two  or  three  tablespoonfuls 
cornmeal,  oatmeal,  wheatena,  hominy,  or  rice 


76  Feeding  after  the  First  Year 

(all  cooked  four  hours  the  day  before  in 
water),  served  with  butter  or  milk,  with  or 
without  sugar.  Glass  of  milk.  Bread  stuffs. 

9  A.M.  Juice  of  one  orange  or  three  ounces 
prune  juice. 

12 130  P.M.  One  or  two  tablespoonfuls 
scraped  steak,  chop  or  minced  chicken  or  soft 
boiled  egg.  Baked  or  mashed  potato.  One  or 
two  tablespoonfuls  spinach,  asparagus,  string 
beans,  peas,  squash,  white  turnip,  stewed  car- 
rots, stewed  celery  or  stewed  onions.  Des- 
serts: Stewed  apple,  stewed  prunes,  baked 
apple,  rice,  bread  or  tapioca  pudding.  Gela- 
tine pudding  with  lemon,  vanilla  or  orange 
flavor.  No  milk  at  this  meal.  Bread  stuffs. 
Rest  one  and  one-half  hours  after  this  meal. 

4  P.M.  Drink  of  milk  and  piece  of  toast  or 
plain  cracker. 

6  P.M.  Two  tablespoonfuls  farina  or  cream 
of  wheat  (cooked  two  hours  in  water),  or  one 
of  above  cereals  served  as  directed.  Drink  of 
milk  or  eight  ounces  of  chicken  or  mutton 
broth.  Spaghetti.  Desserts :  Custard,  corn- 
starch,  junket.  Cream  cheese  or  honey  on 
bread  or  crackers.  Bread  Stuffs:  Wheats- 
worth  biscuit.  Whole  wheat  bread.  Plain 
bread.  Zwieback.  Holland  Rusk.  Toast. 


Feeding  after  the  First  Year  77 

From  the  third  to  the  fifth  year:  three  meals 
daily. 

7:30  A.M.  Three  to  four  tablespooniuls 
cornmeal,  oatmeal,  wheatena,  hominy  or  rice 
(all  cooked  four  hours  the  day  before  in 
water)  served  with  butter  or  milk,  with  or 
without  sugar.  One  slice  of  bacon  or  soft 
boiled  or  poached  egg.  Cereal  may  be  given 
with  either  bacon  or  egg,  or  egg  may  be  given 
alone  with  milk  and  slice  of  bread  and  butter. 
Glass  of  milk.  Bread  stuffs. 

12 130  P.M.  Steak,  chop,  minced  chicken, 
baked  or  boiled  halibut  or  cod  fish.  Baked  or 
mashed  potato.  Two  tablespoonfuls  spinach, 
asparagus,  string  beans,  peas,  squash,  white 
turnip,  stewed  carrots,  stewed  onions,  mashed 
cauliflower.  Desserts :  Stewed  apple,  stewed 
prunes,  baked  apple,  rice,  bread  or  tapioca 
pudding.  Gelatine  pudding  with  orange, 
lemon  or  vanilla  flavor.  Stewed  or  raw 
peaches  and  cherries.  All  stewed  fruits  in 
season,  excepting  strawberries.  Bread  stuffs. 
Rest  one  and  one-half  hours  after  this  meal. 

4  P.M.    Scraped  apple,  pear  or  grapes. 

6  P.M.  Three  or  four  tablespoonfuls  farina 
or  cream  of  wheat  (cooked  two  hours  in 


78  Feeding  after  the  First  Year 

water)  or  one  of  above  cereals,  served  as  di- 
rected. Instead  of  cereal  may  have  spaghetti. 
Glass  of  milk,  or  four  ounces  milk,  four  ounces 
water  and  one  teaspoon  Phillip's  cocoa,  with 
sugar,  or  eight  ounces  chicken  or  mutton  broth. 
Custard,  cornstarch,  junket.  Cream  cheese 
or  honey  on  bread  or  crackers.  (Either  milk, 
cocoa  or  soup  may  be  given  at  night  with  the 
idea  to  variety. )  Bread  Stuffs :  Wheatsworth 
biscuits.  Whole  wheat  bread.  Plain  bread. 
Zwieback.  Holland  Rusk.  Toast. 

From  the  fifth  to  the  seventh  year:  three  meals 
daily. 

7:30  A.M.  Three  to  four  tablespoonfuls 
cornmeal,  oatmeal,  wheatena,  hominy  or  rice 
(all  cooked  four  hours  the  day  before  in 
water)  served  with  butter  or  milk,  either  with 
or  without  sugar.  Bacon,  soft  boiled,  scram- 
bled or  poached  egg  or  minced  chicken.  Glass 
of  milk.  Bread  stuffs.  (The  child  will  do 
best  at  this  age  if  he  is  given  more  than  a  cereal 
and  milk  breakfast. ) 

12:30  P.M.  Steak,  chop,  roast  beef,  roast 
lamb,  poultry,  baked  or  boiled  halibut  or  cod 
fish.  Baked  or  mashed  potato.  Two  table- 
spoonfuls  spinach,  asparagus,  string  beans, 


Feeding  after  the  First  Year  79 

peas,  squash,  white  turnip,  stewed  carrots, 
stewed  celery,  stewed  onions,  mashed  cauli- 
flower. Desserts:  Stewed  apple,  stewed 
prunes,  baked  apple,  rice,  bread  or  tapioca 
pudding.  Gelatine  pudding  with  lemon, 
orange  or  vanilla  flavor.  Raw  and  stewed 
peaches  and  cherries.  All  stewed  berries  in 
season,  except  strawberries.  Bread  stuffs. 
Rest  one  and  one-half  hours  after  this  meal. 

4  P.M.     Raw  apple,  pear,  grapes  or  banana. 

6  P.M.  Three  tablespoon fuls  farina  or  cream 
of  wheat  (cooked  two  hours  in  water)  or  one 
of  above  cereals  served  as  directed.  Glass  of 
milk  or  four  ounces  milk,  four  ounces  water 
and  one  teaspoonful  Phillip's  cocoa,  or  eight 
ounces  chicken  or  mutton  broth.  When  broth 
is  given  stewed  fruit  to  be  given  as  dessert.  In- 
stead of  cereal  may  have  spaghetti.  Desserts : 
Custard,  cornstarch,  junket.  Cream  cheese 
or  honey  on  bread  or  crackers.  Bread  Stuffs : 
Wheatsworth  biscuit.  Whole  wheat  bread. 
Plain  bread.  Zwieback.  Holland  Rusk.  Toast. 

From  the  seventh  to  the  eleventh  year:  three 
meals  daily. 

7:30  A.M.  Cornmeal,  oatmeal,  wheatena, 
hominy,  rice  (all  cooked  four  hours  the  day 


8o  Feeding  after  the  First  Year 

before  in  water)  served  with  butter  or  milk, 
either  with  or  without  sugar.  Occasionally  a 
dried  cereal  may  be  given — shredded  wheat, 
cornflakes,  puffed  rice  or  puffed  wheat.  Bacon, 
soft  boiled,  scrambled  or  poached  egg,  minced 
chicken  or  broiled  fish.  Glass  of  milk.  Bread 
stuffs. 

12  130  P.M.  Steak,  chop,  roast  beef,  roast 
lamb,  poultry,  baked  or  boiled  halibut  or  cod 
fish.  Baked  or  mashed  potato.  Spinach, 
asparagus,  string  beans,  peas,  squash,  white 
turnip,  stewed  carrots,  stewed  celery,  stewed 
onions,  mashed  cauliflower.  Raw  celery  and 
lettuce.  No  milk  at  this  meal.  Desserts : 
Stewed  apple,  stewed  prunes,  baked  apple,  rice, 
bread  or  tapioca  pudding.  Gelatine  pudding 
with  orange,  lemon  or  vanilla  flavor.  Raw 
and  stewed  peaches  and  cherries.  All  stewed 
berries  in  season,  except  strawberries.  Bread 
stuffs. 

6  P.M.  Farina  or  cream  of  wheat  (cooked 
two  hours  in  water)  or  one  of  above  cereals 
served  as  directed.  Glass  of  milk  or  cocoa. 
Chicken  or  mutton  broth  or  dried  pea  or  bean 
soup.  When  soup  is  given  stewed  fruit  to 
be  given  as  dessert.  Instead  of  cereal  may  have 
spaghetti  or  baked  potato  or  two  to  three  table- 


Cooking  of  Vegetables       81 

spoonfuls  of  green  vegetables.  Desserts : 
Custard,  cornstarch,  junket.  Cream  cheese  or 
honey  on  bread  or  crackers.  Bread  Stuffs : 
Wheatsworth  biscuit.  Whole  wheat  bread. 
Plain  bread.  Holland  Rusk.  Zwieback. 
Toast. 

COOKING  OF  VEGETABLES 

Select  young  tender  vegetables,  wash  thor- 
oughly, cook  in  a  small  amount  of  water  until 
they  can  readily  be  mashed  with  a  fork.  They 
should  be  mashed  through  a  coarse  sieve  until 
the  child  is  three  years  old.  Then  always  mash 
with  a  fork. 

HOW   THE  CHILD   SHOULD   BE  FED 

In  the  foregoing  articles  on  feeding  the 
author  has  endeavored  to  suggest  the  nature 
of  the  food  required  by  the  growing  child, 
and  the  intervals  at  which  food  should  be 
given.  This,  however,  does  not  entirely  cover 
the  subject.  A  child  should  never  dine  with 
adults  until  he  can  have  adult  diet,  if  the  cir- 
cumstances of  the  family  will  permit  him  to 
dine  alone  or  with  other  children.  It  is  a 
species  of  cruelty  to  expect  a  hungry  child  of 


82  How  the  ChUd  Should  be  Fed 

tender  age  to  sit  at  the  table,  see  and  smell  the 
fragrant  dishes,  and  be  forced  to  content  him- 
self without  complaint  with  his  restricted  fare. 
The  author  recalls  this  custom  as  a  cause  of 
many  tears,  disputes,  and  fistic  encounters  with 
attendants,  which  formed  no  small  part  of  the 
daily  routine  of  his  early  life. 

In  feeding,  the  spoon  or  fork  must  come  in 
contact  only  with  the  food  and  the  child's 
mouth;  when  not  in  use  it  should  be  allowed 
to  rest  on  the  clean  table-cloth.  If  it  falls  to 
the  floor  by  accident  it  should  be  dipped  in 
boiling  water  before  using  it.  Under  no  cir- 
cumstances should  a  feeding  utensil  be  allowed 
to  come  in  contact  with  the  lips  of  the  nurse 
or  mother;  time  and  again  I  have  seen  mothers 
and  nurses  sip  or  swallow  the  first  teaspoon ful 
of  the  food  which  is  to  be  given,  to  determine 
if  it  is  of  the  proper  temperature.  At  other 
times,  when  the  food  is  not  particularly  attrac- 
tive to  the  child,  they  will  place  the  spoon  in 
their  mouths  as  though  they  intended  to  take 
it  themselves.  Others  will  remove  from  the 
spoon  with  their  own  lips  adhering  particles 
of  food. 

There  are  few  more  reprehensible  practices 
than  the  foregoing,  and  if  parents  knew  the 


Condensed  Milk  (Sweetened)  83 

dangers  to  which  their  children  are  thus  sub- 
jected they  would  not  for  one  instant  tolerate 
them.  Any  one  of  the  many  forms  of  patho- 
genic bacteria  may  be  most  readily  transferred 
to  the  mouth  of  the  child  in  this  way.  It  is 
unquestionably  a  means  of  infection  with 
tuberculosis,  diphtheria,  and  syphilis.  The 
germs  of  tuberculosis  and  diphtheria  are  fre- 
quently found  in  the  mouths  of  perfectly 
healthy  adults.  They  cause  no  symptoms  of 
disease  because  of  the  normal  power  of  resis- 
tance of  such  adults.  The  resisting  powers  of 
the  child,  however,  to  these  micro-organisms 
are  very  slight,  and  when  they  are  carried  to 
the  delicate  mucous  membrane  of  the  infant's 
mouth  and  throat  they  thrive  actively,  the  child 
develops  diphtheria  or  tuberculosis,  and  the 
family  grieve  and  wonder  how  the  child  could 
ever  have  contracted  the  disease. 

CONDENSED  MILK  (SWEETENED) 

Canned  condensed  milk,  sweetened,  should 
never  be  selected  as  a  food  for  a  baby  if  the 
mother  can  afford  to  buy  cows'  milk  and  can 
learn  how  to  prepare  and  care  for  it.  The 
child's  natural  food  is  the  mother's  milk; 


84  Condensed  Milk  (Sweetened) 

this  is  what  he  has  a  right  to  demand.  If 
mothers'  milk  cannot  be  furnished  we  must 
give  a  substitute  which  will  provide  the  baby 
with  the  nourishment  contained  in  mothers' 
milk.  Analyses  by  many  chemists  of  thou- 
sands of  samples  of  good  mothers'  milk  show 
that  it  contains  approximately  3.5  per  cent, 
to  4  per  cent,  of  fat,  1.5  per  cent  of  proteid, 
and  7  per  cent,  of  sugar.  Condensed  milk, 
diluted  one  to  twelve,  i.e.,  one  part  condensed 
milk  to  twelve  parts  of  water, — the  strength 
taken  by  a  three-months-old  child, — will  give 
a  food  containing  .5  per  cent,  of  fat  and  .6 
per  cent,  of  proteid,  and  4  per  cent,  of  sugar. 
Compare  these  figures  with  the  amount  of  fat, 
sugar,  and  proteid  contained  in  mothers'  milk 
and  it  will  readily  be  seen  that  the  baby  is  not 
getting  nearly  as  much  nourishment  as  Nature 
would  furnish  him.  If  the  mixture,  using  the 
condensed  milk,  is  made  in  the  proportion  of 
one  part  condensed  milk  to  eight  parts  of  water 
— the  proper  strength  for  a  six-months-old 
child — there  will  still  be  less  than  i  per  cent,  of 
fat,  and  a  lower  proteid  than  in  mothers'  milk. 
Condensed  milk  has  its  uses,  however.  Many 
mothers  cannot  afford  to  buy  fresh  cows'  milk. 
Some  have  no  refrigerator  or  ice-box  in  which 


Condensed  Milk  (Sweetened)  85 

to  keep  it.  Condensed  milk,  on  account  of  the 
cane  sugar  which  has  been  added  to  it,  will 
remain  fresh  for  two  or  three  days  after  it  has 
been  opened.  It  is  a  most  inexpensive  means 
of  feeding  the  baby.  Further,  its  prepara- 
tion is  exceedingly  simple,  and  many  mothers 
are  too  ignorant  to  appreciate  the  importance 
of  the  careful  preparation  of  cows'  milk. 

Condensed  milk  is  for  many  an  absolute 
necessity;  but  though  children  manage  to  live 
on  it,  they  never  thrive  satisfactorily.  They 
all  show  evidence  of  some  degree  of  rickets, 
unless  fat  in  some  form,  e.g.,  cod-liver  oil  or 
cream,  is  given  in  addition,  to  supplement  the 
food :  and  very  few  children  can  take  cod-liver 
oil  during  the  summer  months.  There  is  an- 
other class  of  children  for  whom  condensed 
milk  has  served  us  well  at  various  times.  They 
are  the  young,  delicate  infants,  with  very  weak 
digestive  powers.  Their  mothers  cannot  nurse 
them,  wet-nurses  are  impossible,  and,  for  some 
reason,  the  smallest  amount  of  cows'  milk, 
most  carefully  adapted,  cannot  be  tolerated;  a 
single  teaspoonful  of  milk  or  cream  in  two 
ounces  of  plain  water,  whey,  weak  milk-sugar 
water,  or  barley  water  produces  colic  and 
diarrhoea.  I  have  successfully  fed  several  of 


86  Condensed  Milk  (Sweetened) 

these  infants  on  a  mixture  consisting  of  one 
part  of  condensed  milk  and  twelve  parts  of 
water.  I  prefer  the  unsweetened  variety.  For 
some  unexplained  reason  these  children  digest 
the  condensed  milk  without  any  inconvenience 
and  do  fairly  well  for  a  few  weeks,  when  the 
secretion  of  the  digestive  juices  will  be  better 
established  and  a  weak  adapted  cows'-milk 
mixture  will  be  borne.  Condensed  milk  is 
also  useful  in  travelling.  During  journeys  by 
land  and  sea,  condensed  milk  with  boiled  water 
will  furnish  satisfactory  food  for  a  limited 
time  at  a  minimum  amount  of  trouble. 

The  following  formulae  may  be  found  of 
service  to  those  who  for  any  reason  are  forced 
to  use  a  temporary  substitute  for  adapted 
cows'  milk: 

First  month  of  life:  I  part  of  condensed  milk 
to  1 6  of  water. 

Second  month:  I  part  of  condensed  milk  to 
14  of  water. 

Third  month:  I  part  of  condensed  milk  to  12 
of  water. 

Fourth  to  sixth  month:  I  part  of  condensed 
milk  to  10  of  water. 

After  the  sixth  month:  I  part  of  condensed 
milk  to  from  8  to  10  of  water. 


The  Proprietary  Foods       87 

Condensed  milk,  unsweetened:  In  the  un- 
sweetened condensed  milk  known  on  the 
market  as  evaporated  milk,  we  have  a  very 
helpful  means  in  the  feeding  of  many  delicate 
infants.  Through  the  processes  of  evapora- 
tion the  milk  is  made  easier  of  assimilation 
by  the  child.  It  is  used  after  the  fashion  of 
fresh  cows*  milk  through  the  addition  of 
water,  sugar,  barley,  lime-water,  etc.  One 
ounce  represents  2  and  two-fifths  ounces  of 
fresh  cows'  milk.  This  concentration  has  to  be 
considered  in  arranging  the  formula. 

THE  PROPRIETARY  FOODS 

The  foods  on  the  market  prepared  for  pur- 
poses of  infant  feeding  are  almost  without 
number.  From  our  knowledge  of  the  com- 
position of  mothers'  milk  we  learn  what  nu- 
tritional elements  and  approximately  in  what 
relative  proportions  these  elements  must  exist 
in  order  to  supply  the  child  with  the  food 
which  Nature  intended  him  to  have.  The  ex- 
amination of  the  milk  of  thousands  of  nursing 
women  shows  that  it  ranges  from  2.5  to  4  per 
cent,  fat,  6  to  7  per  cent,  sugar,  and  i  to  1.5 
per  cent,  proteid.  These  figures  may  be  put 
down  as  the  normal  limits  of  human  milk,  and 


88      The  Proprietary  Foods 

they  are  so,  simply  because  the  infant  will 
thrive  and  grow  when  the  nutritional  elements 
in  approximately  the  above  proportions  are 
supplied  to  him.  It  is  within  these  limits  that 
the  food  must  be  kept  in  order  that  there  may 
be  normal  growth  and  development;  though  of 
course,  wide  variations  from  these  may  be  of 
temporary  occurrence.  While  the  child  may 
exist  and  temporarily  do  fairly  well  on  a  per- 
centage of  fat  lower  than  2.5,  he  will  invariably 
show  defective  growth  if  the  proteid 
remains  persistently  under  i  per  cent.  The 
chief  disadvantage  in  the  infant  foods  which 
are  used  without  the  addition  of  cows'  milk, 
lies  in  the  fact  that  they  do  not  contain  the 
nutritional  elements  as  they  exist  in  normal 
breast-milk,  and  besides,  of  necessity,  they  are 
all  cooked  foods. 

In  selecting  a  substitute  for  mothers'  milk 
one  point  is  to  be  kept  in  mind,  viz.,  the  sub- 
stitute should  contain,  in  a  readily  assimilable 
form,  the  nutritional  elements  in  approxi- 
mately the  proportions  and  forms  in  which 
they  exist  in  mothers'  milk.  All  other  feeding 
is  defective.  It  is  not  well  to  put  too  much 
reliance  on  the  analysis  sometimes  published 
by  the  proprietary  food  manufacturer.  This 


The  Proprietary  Foods       89 

type  of  food  is  decidedly  weak  in  animal  fat, 
for  the  reason  that  there  is  no  means  of  keep- 
ing more  than  a  small  percentage  of  it  in 
a  food  without  its  becoming  rancid.  When 
considerable  percentages  are  indicated  in  the 
analysis  it  is  certain  that  it  does  not  consist 
of  butter  fat.  The  quantity  of  animal  milk 
proteid  is  likewise  deficient.  Scurvy  is  not 
an  infrequent  result  of  the  exclusive  use  of 
these  foods. 

The  uses  of  proprietary  dried-milk  foods. 
— It  is  to  be  remembered  that  this  type  of 
food  is  condemned  because  of  its  being  an 
unsuitable  food  when  used  exclusively  and 
persistently.  In  constipation  in  "runabout" 
and  older  children  who  are  on  a  general  diet, 
the  importance  of  milk  in  the  nutrition  is  a 
secondary  one,  and  is  often  an  important  fac- 
tor in  the  production  of  constipation.  In  these 
cases  cows'  milk  may  be  replaced  by  one  of  the 
proprietary  dried-milk  foods  which  has  a  laxa- 
tive effect,  with  a  good  deal  of  advantage.  I 
sometimes  employ  them  further  in  other  dis- 
ordered states.  During  acute  illness  and  in 
convalescence  from  illness  and  in  certain  forms 
of  malnutrition  they  are  usually  readily  di- 
gested and  may  help  us  over  difficult  places. 


90      The  Proprietary  Foods 

Proprietary  foods  to  which  fresh  cows'  milk 
is  added. — These  are  not  foods  in  the  usual  ac- 
ceptation of  the  term,  and  if  they  are  used 
alone  independent  of  milk  the  patient  will  soon 
present  a  sorry  spectacle.  They  are  sugars 
largely,  being  composed  of  maltose  and  dex- 
trin, which  are  derived  from  starch.  Some 
contain  a  considerable  quantity  of  unconverted 
starch.  When  added  to  the  water  and  milk 
mixtures  they  furnish  the  soluble  carbohy- 
drates in  the  form  of  maltose  and  free  starch, 
and  thus  fulfill  this  function  in  the  food  with 
as  good  results  as,  but  usually  no  better  than, 
would  milk-sugar  and  a  cereal  gruel.  Maltose 
is  a  laxative  sugar.  In  case  of  constipation  in 
the  bottle-fed  it  may  replace  the  milk-sugar  in 
equal  quantity,  and  as  such  may  be  used  with 
decided  advantage  in  some  cases.  In  others, 
this  change  to  maltose  is  without  effect.  The 
claim  that  when  added  to  cows'  milk  these 
proprietary  foods  increase  the  liability  to 
scurvy  is  without  foundation.  If  the  milk  is 
given  uncooked,  the  child  will  not  have  scurvy, 
regardless  of  the  nature  of  the  sugar;  if  the 
milk  is  heated  to  160°  or  170°  F.,  the  child 
may  have  scurvy  regardless  of  the  sugar. 

According  to  my  observation,  the  statement 


The  Proprietary  Foods       91 

that  the  addition  of  maltose  to  cows'  milk 
facilitates  its  digestion  is  unfounded.  I  have 
tried  it  in  many  cases,  but  have  never  been 
able  in  consequence  to  use  a  stronger  cows'- 
milk  mixture.  The  true  test  of  such  a  measure 
is  its  use  in  the  delicate  and  in  difficult  feeding 
cases,  and  not  in  well  babies  who  thrive  regard- 
less of  the  sugar  employed.  The  maltose 
preparations,  then,  in  the  sense  that  they  may 
contain  a  small  amount  of  proteid  and  a  laxa- 
tive sugar,  are  useful  and  to  be  recommended 
when  such  a  carbohydrate  is  needed. 

The  'proprietary  beef  foods. — Numerous 
preparations  of  this  nature  are  on  the  market 
and  there  has  been  abundant  opportunity  to 
test  their  value.  Without  going  into  a  lengthy 
discussion  as  to  how  and  under  what  condi- 
tions these  preparations  have  been  used,  it  is 
sufficient  to  say  that  as  a  means  of  nutrition 
in  children  they  play  a  very  unimportant  part. 
Their  principal  use  is  in  illness,  in  which  they 
act  as  a  stimulant,  and  to  a  less  degree  as  a 
food.  They  all  make  weak  proteid  mixtures 
when  diluted  so  that  the  child  can  take  them. 
The  possibility  of  supplying  any  great  amount 
of  nutrition  to  the  economy  by  their  use  is 
small ;  occasionally,  however,  they  may  be  used 


92          Milk  for  Travelling 

to  advantage.  When  milk  is  withdrawn  they 
may  be  added  to  the  cereal  gruel  substitute.  If 
there  is  diarrhoea,  great  care  must  be  exercised, 
as  the  proprietary  beef  preparations  as  well 
as  beef -juice  may  increase  it.  On  account  of 
the  creatinin  which  they  contain,  they  should 
not  be  given  in  any  of  the  forms  of  nephritis. 
Another  feature  which  limits  their  use  is  that 
a  child  soon  tires  of  them.  They  can  rarely  be 
given  more  than  two  or  three  times  in  twenty- 
four  hours.  Valentine's  is  the  preparation  I 
usually  select.  It  may  be  given  in  solution — 
one-quarter  to  one-half  teaspoonful  to  six 
ounces  of  the  diluent. 

MILK  FOR  TRAVELLING 

In  making  long  journeys  with  infants  by 
land  or  water,  the  feeding  of  the  child  is  an 
important  matter,  and  advice  is  often  sought 
by  mothers  who  wish  to  make  the  contem- 
plated trip  with  the  least  possible  risk.  It  is, 
of  course,  desirable  that  no  change  be  made  in 
the  milk  commonly  used,  and  there  are  means 
of  treating  the  milk  and  of  keeping  it  which 
enables  us  to  assure  the  patient  of  reasonable 
safety.  It  is  my  custom  with  city  children  to 


Milk  for  Travelling          93 

have  the  milk  prepared  at  the  Walker-Gordon 
Laboratory,  where  at  a  trifling  expense  small 
ice-boxes  can  be  obtained  which  contain  suffi- 
cient space  for  a  few  days'  supply  of  milk  and 
which  can  be  conveniently  carried  on  cars  and 
boats.  They  have  also  larger  boxes  with  a 
capacity  of  twelve  quarts,  which  may  be  used 
for  an  ocean  voyage.  The  smaller  box  will 
need  refilling  with  ice  once  or  twice  a  day, 
which  is  usually  readily  secured.  The  larger 
box,  for  ocean  voyages,  is  packed  in  ice  and 
placed  in  a  cold-storage  room  of  the  vessel  and 
will  not  need  repacking  during  the  trip.  Labo- 
ratory milk,  however,  is  available  for  com- 
paratively few. 

Milk  prepared  at  home  for  a  journey  should 
be  cooled  to  45°  F.  as  soon  as  it  is  drawn,  and 
kept  at  this  temperature  until  it  can  be  ster- 
ilized at  a  temperature  of  2i2°F.  for  twenty 
minutes.  It  then  should  be  cooled  rapidly  to 
at  least  50°  F.  and  kept  at  this  point  until  used. 
These  directions  can  be  carried  out  by  any 
intelligent  family.  When  this  is  done  the  milk 
will  be  safe  for  use  for  the  time  required — 
from  seven  to  eight  days.  Even  the  sugges- 
tions as  to  the  making  of  an  ice-box  can  be 
followed  in  any  town  or  village.  All  that  is 


94          Diet  During  Illness 

required  is  the  ice-box,  one-quart  fruit  jars 
or  one-quart  milk  bottles,  and  clean  milk. 
Those  who  for  any  reason  cannot  avail  them- 
selves of  the  milk  thus  preserved  will  find  in 
canned  condensed  milk  a  fairly  good  substitute. 
If  kept  on  ice  and  wrapped  in  a  clean  towel,  a 
can  of  condensed  milk  may  safely  be  used  for 
three  days  after  opening.  Formulas  suited  for 
the  various  months  of  infancy  will  be  found 
in  the  section  on  condensed  milk  (page  86). 

DIET  DURING  ILLNESS 

The  digestive  capacity  of  every  child  is 
diminished  during  illness,  depending  largely 
upon  the  age  of  the  child  and  the  severity  of 
the  disease.  The  younger  the  child,  the  greater 
the  incapacity.  This  is  fairly  constant  with 
all  the  ailments  of  childhood,  including,  of 
course,  those  which  directly  affect  the  gastro- 
enteric  tract.  In  a  moderately  severe  bron- 
chitis, with  a  degree  or  two  of  fever,  the 
digestive  capacity  is  slightly  diminished  and  a 
25  per  cent,  reduction  in  the  strength  of  the 
food  will  answer.  During  the  critical  stage  of 
a  lobar  pneumonia  the  digestive  powers  are 
held  in  abeyance  and  predigested  foods  and 


Diet  During  Illness          95 

alcohol  must  sustain  the  patient.  During  an 
attack  of  measles,  scarlet  fever,  broncho- 
pneumonia,  or  diphtheria  in  bottle-fed  infants, 
at  the  height  of  the  disease,  it  is  my  custom  to 
reduce  the  strength  of  the  food  one-half  by 
the  addition  of  water,  to  make  up  for  the  quan- 
tity removed.  For  ailments  of  lesser  severity, 
such  as  bronchitis,  with  a  temperature  of  100° 
to  ioi°F.,  or  chicken-pox,  or  mild  measles,  I 
reduce  the  strength  of  the  food  from  one- 
fourth  to  one-third.  In  any  mild  ailment  or 
injury  which  confines  a  child  to  its  bed,  the 
food  strength  should  be  cut  down,  for  inactivity 
as  well  as  disease  lessens  the  digestive  capacity. 
Among  nurslings  and  the  bottle-fed  these 
precautions  are  particularly  necessary.  A 
child  with  fever  is  apt  to  be  thirsty  and  to  take 
more  food  than  in  health.  This  is  frequently 
the  case  in  summer  diarrhoea.  In  order  to 
avoid  this  taking  of  too  much  food,  I  not  only 
order  the  milk  to  be  diluted  for  the  bottle-fed 
but  I  instruct  the  mothers  of  nurslings  to  give 
a  drink  of  water  immediately  before  each 
nursing  and  between  nursings,  and  then  to  al- 
low the  child  to  nurse  only  one-half  or  two- 
thirds  the  usual  time.  For  the  bottle-fed,  one- 
half  to  two-thirds  of  the  contents  of  each  bottle 


96          Diet  During  Illness 

is  removed  and  the  quantity  replaced  by  boiled 
water,  so  that  the  amount  of  fluid  given  re- 
mains the  same. 

If  the  child  is  a  "runabout,"  over  two  years 
of  age,  he  is  given  broths  and  thin  gruel — one- 
half  milk  and  one-half  gruel.  By  carefully 
watching  the  stools,  thus  fitting  the  food  to 
the  child's  capacity,  we  will  avoid  grave  intes- 
tinal complications  which,  during  the  summer, 
often  prove  to  be  more  serious  than  the  original 
ailment.  In  the  acute  gastro-enteric  troubles, 
and  in  typhoid  fever,  all  milk  must  be  discon- 
tinued. 

The  art  of  feeding  in  illness. — Not  only  is 
food  oftentimes  taken  in  insufficient  quantity 
in  illness,  but  in  many  cases  it  is  absolutely  re- 
fused. In  other  cases,  during  coma  and 
asthenic  states,  swallowing  is  impossible.  In 
delirium  and  in  conditions  of  collapse  nourish- 
ment must  be  given,  and  when  this  is  impossi- 
ble by  the  natural  method,  we  have,  as  tem- 
porary substitutes,  gavage,  oil  inunctions,  and 
rectal  feeding — all  of  which  must  be  prescribed 
by  the  attending  physician  to  suit  the  individual 
case. 

Forced  feeding. — Forcing  the  child  to  take 
nourishment  by  the  mouth  is  rarely  necessary. 


Diet  During  Illness          97 

Coaxing  and  bribing  ordinarily  succeed  far 
better.  For  a  child  from  three  to  five  years 
of  age  a  bright  new  penny  possesses  much 
persuasive  power.  The  child  will  usually 
take  its  food  better  from  those  to  whom  it  is 
accustomed,  like  the  mother  or  nursery-maid. 
The  trained  nurse  should  understand  that 
while  unacquainted  with  the  patient,  the 
simpler  requirements  of  the  child  are  to  be 
looked  after  by  others  to  whom  the  patient 
is  accustomed.  The  nourishment  should  be 
as  palatable  as  possible  and  served  in  bowls, 
cups,  or  plates  that  are  attractive  to  the 
patient  because  of  color,  pictures,  or  pecu- 
liarities of  shape.  Junket,  flavored  with 
vanilla,  served  cold  is  a  favorite  food  for 
sick  children  of  the  "runabout"  age.  Frozen 
custard,  and  home-made  ice-cream,  made  with 
one-third  cream  and  two-thirds  milk,  will 
usually  be  well  taken.  Toast,  dry  bread,  and 
crackers  made  in  peculiar  shapes  are  attractive 
to  the  child.  In  not  a  few  cases  I  have  suc- 
ceeded in  feeding  satisfactorily  children  two 
or  three  years  old,  when  several  other  schemes 
had  failed,  by  allowing  the  temporary  return  to 
the  bottle,  from  which  they  had  been  weaned 
for  a  year  or  so. 


98  Vomiting 

In  these  difficult  feeding  cases  the  child's 
peculiarities  and  wishes  must  be  studied. 
Children  in  illness  require  water.  Oftentimes 
they  will  take  it  in  insufficient  quantities. 
Those  who  refuse  plain  water  will  often  take 
ginger  ale,  sarsaparilla,  or  vichy.  In  the  event 
of  these  drinks  being  well  taken,  they  may  be 
given  freely.  In  the  acute  infectious  diseases, 
which  include  pneumonia,  free  water-drinking 
is  a  therapeutic  measure  of  no  mean  value. 

VOMITING 

A  sudden  attack  of  vomiting,  with  fever, 
may  usher  in  any  serious  illness.  Thus,  it 
may  be  the  initial  symptom  of  pneumonia, 
scarlet  fever,  or  meningitis.  By  far  the  most 
usual  cause,  however,  will  be  found  intimately 
connected  with  the  stomach,  usually  an  acute 
attack  of  indigestion.  Bottle-fed  children 
furnish  the  greatest  number  of  patients,  as 
these  children  are  often  overfed. 

Management. — With  the  onset  of  a  sharp 
attack  of  vomiting,  particularly  if  it  occurs 
during  hot  weather,  the  milk  diet  should  im- 
mediately be  discontinued.  Small  quantities  of 
boiled  water,  one-half  to  two  ounces  of  barley 


Habitual  Vomiting          99 

water,  or  rice  water,  or  plain  broths  may  be 
given  every  hour  or  two.  In  the  obstinate 
cases,  quite  a  period  of  rest  should  be  given  to 
the  stomach.  From  twenty- four  to  thirty-six 
hours  will  often  be  necessary  before  the  child 
will  be  able  to  retain  even  a  teaspoonful  of 
water.  One  teaspoonful  of  bicarbonate  of 
soda  added  to  one  glass  of  quite  hot  water  will 
often  be  retained  if  given  in  small  quantities — 
one  teaspoonful  every  few  minutes.  No  milk 
should  be  given  until  the  vomiting  has  ceased 
for  at  least  two  days.  When  the  milk  is  re- 
sumed it  should  be  diluted  two  or  three  times 
with  water  or  barley  water  and  at  first  only 
a  small  quantity  of  the  mixture  given.  If  the 
stomach  bears  the  food  well  its  strength  may 
gradually  be  increased  by  an  additional  half- 
ounce  or  ounce  of  milk  to  each  feeding  daily, 
until  the  former  diet  is  resumed. 


HABITUAL  VOMITING 

Many  infants  regurgitate  or  vomit  a  por- 
tion of  every  feeding.  This  usually  means  the 
child  has  been  or  is  overfed.  He  is  given  the 
food  too  strong,  too  much  sugar  or  fat,  or  the 
amount  is  greater  than  his  capacity,  or  he  is 


ioo        Habitual  Vomiting 

fed  at  too  frequent  intervals.  In  either  case 
the  stomach  relieves  itself.  Many  of  these 
children  who  regurgitate  after  each  feeding 
thrive  finely  in  spite  of  the  loss.  Enough  is 
retained  for  their  nourishment,  and  they  grad- 
ually become  accustomed  to  the  strong  food 
and  no  serious  harm  results.  Such  a  stomach, 
however,  is  liable  to  behave  very  badly  during 
hot  weather.  During  any  illness,  in  fact, 
which  taxes  the  patient's  strength,  the  dis- 
ordered stomach  stands  ready  to  furnish  an 
unpleasant  complication. 

Habitual  vomiting  occurs  also  in  infants  in 
whom  there  is  an  obstruction  at  the  outlet  of 
the  stomach.  The  condition  may  be  one  of 
simple  spasm  of  the  parts  or  there  may  be  a 
muscular  growth  which  resists  the  passage  of 
food  into  the  intestines.  A  condition  known 
as  rumination  explains  habitual  vomiting  in 
a  few  infants.  In  such  cases  the  child  volun- 
tarily forces  the  food  from  the  stomach  into 
the  mouth,  a  portion  is  reswallowed  but  the 
greater  is  regurgitated. 

All  cases  of  habitual  vomiting,  particularly 
if  there  is  loss  in  weight,  should  be  brought  to 
the  attention  of  the  physician. 

Management. — The  treatment   of   ordinary 


Malnutrition  and  Marasmus  101 

habitual  vomiting  in  the  bottle-fed  is  by  a  suit- 
able adaptation  of  the  food,  usually  by  cutting 
down  the  fat  and  sugar  and  by  stomach  wash- 
ing. Among  the  breast-fed  the  breast-milk 
will  have  to  be  examined  and,  if  found  unsuit- 
able, corrected  if  possible.  If  too  frequent 
nursings  or  night  nursings  have  been  allowed 
they  should  be  discontinued.  The  abdominal 
binder  should  never  be  tightly  applied  in  vomit- 
ing babies. 

MALNUTRITION  AND  MARASMUS 

By  malnutrition  we  understand  that  con- 
dition in  which  a  child  for  some  reason  fails 
to  gain  in  weight  or  loses  steadily  for  a  con- 
siderable period  of  time.  Cases  present  all 
degrees  of  severity,  from  those  in  which  there 
is  merely  a  temporary  loss  of  weight,  to  those 
of  an  extreme  degree  of  malnutrition,  which 
latter  condition  we  term  marasmus.  A  ma- 
rasmatic  infant  presents  one  of  the  most  piti- 
ful pictures  we  are  called  to  look  upon :  the 
dry  skin  drawn  tightly  over  the  fleshless  bones, 
the  sunken  eye,  the  distended  abdomen,  the 
anxious,  tired  expression,  and  the  whining  cry 
furnish  a  picture  of  starvation  so  pathetic  that 


KM?  Malnutrition  and  Marasmus 

only  those  hardened  by  long  familiarity  with 
such  cases  can  look  upon  them  unmoved. 

Causes  of  marasmus. — When  the  history  of 
such  infants  has  been  looked  into  it  will  be 
learned  that  errors  in  feeding  contributed 
largely  to  bringing  them  to  their  woeful 
condition.  Many  of  these  children  came  into 
the  world  strong  and  vigorous,  the  mothers 
were  unable  to  nurse  them,  and  the  food 
selected  did  not  agree  with  them.  Cows'  milk, 
perhaps,  was  given,  unsuitably  adapted, — 
it  usually  is  given  too  strong  to  young  infants, 
— at  any  rate  it  disagreed,  and  the  proprietary 
meal  foods  were  brought  into  use,  one  after 
another,  as  they  were  suggested  by  well-mean- 
ing friends,  each  to  do  its  share  of  damage  and 
in  turn  to  be  discarded.  The  digestive  organs 
bore  the  ill-usage  for  a  time,  but  soon  became 
so  disturbed  that  the  utilization  of  rational 
food  was  out  of  the  question.  Many  of  these 
children  finally  reach  the  point  where  predi- 
gested  foods  fail  to  be  assimilated;  such  cases, 
of  course,  are  hopeless. 

Lay  advice. — It  is  a  source  of  amusement 
oftentimes  to  note  the  assurance  with  which 
laymen  will  advise  a  mother  that  such  and 
such  a  food  is  the  only  one  for  the  baby,  when 


Malnutrition  and  Marasmus  103 

they  possess  neither  the  intelligence  nor  the 
training  necessary  to  judge  of  the  child's  di- 
gestive peculiarities  or  capacity;  in  fact,  they 
know  no  more  of  the  child's  requirements  or 
the  chemical  composition  of  the  food  sug- 
gested, or  even  what  should  be  the  composi- 
tion of  the  baby's  food,  than  does  the 
unfortunate  babe  itself. 

Outcome  of  the  cases. — If  there  is  inherited 
weakness,  or  a  low  vitality  from  any  cause, 
the  downward  course  may  be  very  rapid. 
There  are  two  or  three  weeks  of  suffering, 
and  then  the  end.  If  seen  before  the  vital 
powers  are  at  too  low  an  ebb,  these  children, 
by  very  careful  and  intelligent  management, 
can  be  saved. 

Management. — They  should  be  handled 
only  when  necessary  for  dressing  and  bathing. 
The  nourishment  given  must  at  first  be  very 
weak,  and  its  effects  carefully  watched  from 
day  to  day,  the  strength  and  amount  of  the 
food  being  increased  or  decreased,  as  may  be 
found  necessary  by  the  physician.  A  brine 
bath  should  be  given  daily, — a  tablespoonful 
of  salt  to  a  gallon  of  water.  The  temperature 
of  the  water  should  be  100°  to  105°  F.  The 
child  should  remain  in  the  water  ten  minutes, 


104  Malnutrition  and  Marasmus 

being  rubbed  well  with  the  hand  while  in  the 
water.  When  removed,  it  should  be  placed 
in  a  large  bath  towel  and  dried  quickly. — 
When  dry,  rub  one  tablespoonful  of  unsalted 
lard  or  goose-grease  into  the  skin.  Flannel 
should  be  worn  next  to  the  skin  except  during 
very  warm  summer  weather. 

Excessive  attention  is  bad  for  these  infants. 
They  should  be  kept  very  quiet  between  the 
necessary  feedings  and  bathing. 

Marasmatic  children  when  sleeping  should 
not  be  allowed  to  remain  long  in  one  position; 
they  should  frequently  be  turned  from  the 
back  to  the  side,  and  from  one  side  to  the 
other.  A  hot-water  bottle  to  the  feet  will  often 
be  necessary  when  sleeping. 

Airing. — To  a  child  suffering  from  malnu- 
trition, fresh  aid  is  as  indispensable  as  food. 
During  the  warm  weather  if  he  can  be  pro- 
tected from  the  sun  the  child  should  be  kept 
out  of  doors  from  morning  until  night.  Dur- 
ing the  entire  year  he  should  sleep  with  the 
window  open.  During  the  winter  months  he 
should  be  taken  out  of  doors  for  at  least  two 
hours  every  pleasant  day.  When,  on  account 
of  the  inclement  weather  or  excessive  cold, 
he  cannot  go  out,  he  should  be  dressed  as  for 


Summer  Diarrhoea         105 

the  daily  outing,  taken  into  a  room  all  the  win- 
dows of  which  have  been  open  for  at  least  one- 
half  hour;  here,  placed  in  a  baby-carriage  and 
warmly  covered,  with  a  hot-water  bottle  at  his 
feet,  he  is  allowed  to  enjoy  the  fresh  air  for 
several  hours  each  day.  This  brightens  the  eye, 
brings  color  to  the  cheek,  and  an  invigorated 
baby  returns  to  the  nursery. 

SUMMER  DIARRHCEA 

Summer  diarrhoea  is  the  cause  of  more 
deaths  among  young  children  in  our  large 
cities  than  any  other  one  factor. 

Nature  of  summer  diarrhoea. — Every  illness 
of  this  nature  must  be  considered  as  a  case  of 
poisoning.  The  vomiting  and  diarrhoea  are 
conservative  efforts  on  the  part  of  the  organ- 
ism to  get  rid  of  the  offending  material.  The 
poisoning  may  result  from  direct  infection. 
It  may  be  due  to  bacteria-laden  milk,  unclean 
feeding  apparatus,  or  to  any  means  whereby 
poisonous  germs  find  entrance  into  the  gastro- 
intestinal tract. 

There  may  also  be  an  indirect  infection  or 
self -poisoning  —  an  auto-intoxication.  Heat 
plays  an  important  part  in  these  cases.  The 


io6        Summer  Diarrhoea 

child  is  greatly  depressed;  the  digestive  proc- 
esses are  not  properly  carried  on — the  milk 
taken  from  the  breast  or  bottle  is  not  acted 
upon  by  digestive  juices  of  the  usual  strength 
and  volume;  decomposition  takes  place; 
poisons  are  generated  and  absorbed,  producing 
fever  and  prostration,  the  intestine  endeavors 
to  empty  itself  of  the  offending  material  and 
diarrhoea  results. 

Cholera  infantum,  inflammation  of  the 
bowels,  dysentery — all  very  bad  terms  but  in 
common  use — are  due  primarily  to  the  causes 
above  mentioned. 

Management. — Such  being  the  nature  of 
summer  diarrhoea,  the  duties  of  the  mother 
in  such  cases  should  be  clearly  understood. 
The  intestine  must  be  relieved  of  as  much  as 
possible  of  the  material  which  is  causing  the 
trouble.  For  this  purpose  give  two  tea- 
spoonfuls  of  castor-oil,  and  nourishment  which 
will  not  furnish  a  fertile  soil  for  the  growth 
of  bacteria.  For  this  reason  milk  must  be 
stopped  with  the  first  symptom  of  the  trouble. 
The  mother  will  never  make  a  mistake  in 
these  cases;  in  fact,  many  a  life  will  be  saved 
by  an  immediate  dose  of  castor-oil  and  by 
promptly  stopping  the  milk  diet  before  the 


Summer  Diarrhoea        107 

physician  who  must  always  be  called  arrives. 
Milk,  in  addition  to  furnishing  a  medium  for 
the  growth  of  bacteria,  forms  into  tough  curds 
which  must  pass  the  entire  length  of  the  intes- 
tinal tract,  exciting  a  very  active  peristalsis, 
causing  pain  and  an  increase  in  the  number  of 
passages. 

Milk  substitutes. — The  diet  substituted  for 
milk  should  consist  of  some  cereal  water; 
either  barley,  wheat,  or  rice  may  thus  be  used; 
chicken  or  mutton  broth,  whey,  or  substances 
of  like  nature  may  be  given  alternately  or 
combined  with  the  cereal  waters.  Salt  should 
be  added  to  the  barley  water  if  it  is  given  plain. 
I  prefer  to  give  one  or  two  ounces  of  chicken 
broth  or  mutton  broth  with  the  barley  water. 
A  teaspoon ful  of  sherry  wine  or  one  teaspoon- 
ful  of  liquid  peptonoids  may  be  added  to  the 
barley  water.  Broths  must  be  given  in  small 
amounts,  as  not  infrequently  they  have  a  de- 
cidedly laxative  effect. 

It  is  not  advisable  to  give  one  food  con- 
tinuously, as  the  child  will  tire  of  it.  The 
addition  to  the  barley  water  of  one  of  the  sub- 
stances suggested  will  so  change  its  taste  that, 
if  necessary,  the  diet  may  be  continued  for 
several  days.  The  quantity  should  correspond 


io8        Summer  Diarrhoea 

to  the  amount  of  food  taken  in  health,  but  the 
intervals  between  feedings  should  be  shorter — 
every  two  hours  if  practicable.  For  instruc- 
tions for  cooking  the  cereal  water,  see  For- 
mula, page  315. 

How  milk  is  to  be  resumed. — A  patient  is 
not  to  be  considered  out  of  danger  nor  should 
the  milk  diet  be  resumed  until  the  stools  are 
normal  and  not  over  two  or  three  daily.  In 
many  cases  milk  must  be  excluded  for  two  or 
three  weeks.  When  it  is  resumed,  care  must 
be  exercised  in  not  giving  too  strong  a  mix- 
ture; many  a  relapse  is  due  to  this  error.  The 
first  day  not  over  one-quarter  ounce  of  milk 
should  be  given  in  each  feeding  of  the  barley 
water.  If  this  causes  no  disturbance  one-half 
ounce  may  be  given  the  next  day,  increasing 
from  one-quarter  to  one-half  ounce  daily,  if 
there  is  no  return  of  the  diarrhoea,  until  the 
customary  strength  is  reached.  Many  children 
will  not  be  able  to  digest  nearly  as  strong  a 
mixture  as  they  were  taking  before  their  ill- 
ness, and  the  diluted  milk  mixture  will  have 
to  be  supplemented  by  the  use  of  dextrinized 
cereal  gruels,  cereal  jellies,  scraped  beef,  the 
white  of  an  egg,  and  other  easily  digested  sub- 
stances. Every  year  I  have  patients  who,  after 


Summer  Diarrhoea        109 

an  attack  of  diarrhoea  cannot  take  a  particle 
of  milk  without  harm  until  the  autumn  is  well 
advanced. 

Protein  Milk  and  Lactic  Protein  Milk  and 
Lactic  Acid  Milk  are  preparations  of  milk  of 
different  strengths  that  have  been  treated  with 
the  Bulgarian  bacillus.  They  are  exceeding 
useful  in  summer  diarrhoea  but  should  be  pre- 
scribed by  the  attending  physician.  Milk  so 
prepared  may  be  given  freely  and  earlier  in 
the  disease  which  makes  them  very  desirable 
means  of  supplying  nourishment  at  a  critical 
time. 

Bowel  irrigation. — Washing  out  the  bowels 
once  or  twice  a  day  is  also  very  helpful  in  the 
treatment  of  these  cases  if  the  stools  contain 
any  blood  or  much  mucus.  This  is  done  as 
follows:  A  No.  14  so  ft- rubber  English  cathe- 
ter, one  that  will  not  bend  upon  itself,  if 
properly  used,  is  attached  to  a  fountain 
syringe.  The  bag  should  be  held  three  feet 
above  the  patient,  who  should  lie  on  the  left 
side  with  the  legs  well  drawn  up.  The  tip  of 
the  well-oiled  catheter  is  passed  into  the  rec- 
tum a  distance  of  two  inches,  when  the  water 
is  allowed  to  pass  in  slowly.  The  water  will 
distend  the  parts  and  facilitate  the  further  in- 


no        Summer  Diarrhoea 

troduction  of  the  tube.  Press  the  folds  of  the 
buttocks  together  until  the  colon  is  rilled.  This, 
in  a  child  eighteen  months  of  age,  will  require 
from  twenty- four  to  thirty  ounces  of  water. 
When  not  less  than  one  pint  has  passed  in 
allow  the  water  to  pass  out  alongside  the 
tube. 

Prevention. — A  word  regarding  the  pre- 
vention of  summer  diarrhoea.  It  is  not  enough 
that  the  child  be  given  properly  prepared  pas-^ 
teurized  or  sterilized  milk  or  breast-milk, — he 
must  be  made  comfortable  during  the  hot 
weather.  The  clothing  should  be  of  the  light- 
est. On  very  hot  days,  if  in  the  country,  he 
should  be  kept  in  the  open  air,  in  the  shade; 
if  in  the  city,  the  coolest  room  in  a  house  or 
an  apartment  is  far  better  than  the  dusty 
streets.  Whether  in  the  city  or  country,  on 
very  hot  days  two  or  three  fifteen-minute 
spongings  with  water  at  60°  F.  will  add 
greatly  to  the  child's  comfort. 

Reduction  of  food. — Further,  we  know  that 
the  digestive  capacity  is  lessened  during  the 
heated  term,  and  the  milk  should  be  reduced 
in  strength  from  one-quarter  to  one-third, 
adding  boiled  water  to  take  the  place  of  the 
milk  removed. 


Baths  in 

Cleanliness. — As  infection  may  be  carried 
to  the  feeding  utensils  by  the  hands  of  the 
nurse  or  mother,  she  should  always  wash  them 
most  carefully  with  soap  and  water  before 
handling  bottles  or  nipples,  or  preparing  the 
infant's  food.  Inasmuch  as  other  children 
may  become  infected,  or  reinfection  take  place 
in  the  one  already  ill,  a  child  with  summer 
diarrhoea  should  be  isolated. 

BATHS 

The  newly  born  child  should  be  given  daily 
a  basin-bath  with  lukewarm,  boiled  water  and 
castile  soap  until  the  cord  falls  and  the  navel 
heals.  When  this  has  taken  place  the  tub- 
bath  may  be  given.  The  temperature  of  the 
bath  for  the  very  young  infant  should  not  be 
below  95°  F.  nor  above  100°  F.  Very  young 
children  should  not  be  kept  in  the  water  more 
than  three  minutes.  After  the  third  or  fourth 
month  a  temperature  of  90°  or  95°  F.  is  best, 
the  child  being  kept  in  the  water  about  five 
minutes.  At  this  age  I  prefer  to  have  the  tub- 
bath  given  at  night,  just  before  the  child  is 
put  to  bed.  A  basin-bath  may  be  given  in  the 
morning.  When  the  child  is  a  year  old  and 


Baths 


fairly  vigorous,  the  temperature  of  the  water 
at  the  beginning  of  the  bath  should  be  90°  F. 
This  should  gradually  be  reduced  to  80°  F.  by 
the  addition  of  cold  water,  the  child  being 
vigorously  rubbed  with  the  hand  while  in  the 
water.  The  temperature  of  the  room  should 
be  from  76°  to  80°  F.  during  the  bath,  and 
windows  and  doors  should  be  closed.  When 
removed  from  the  tub  the  baby  should  be  dried 
quickly  and  thoroughly,  and  the  folds  of  the 
skin  should  be  well  powdered.  A  sponge 
should  never  be  used  in  any  portion  of  the 
bathing  process.  It  should  never  be  included 
in  the  nursery  outfit.  It  is  never  clean  after 
it  has  once  been  used. 

Dread  of  the  bath.  —  Some  children  have  a 
dread  of  the  bath,  and  cry  frantically  when 
placed  in  the  water.  This  is  due  to  fear,  and 
may  usually  be  overcome  by  placing  a  sheet 
over  the  tub  and  lowering  the  child  on  it  into 
the  water. 

The  cold  douche.  —  For  "runabouts"  from 
two  to  three  years  old  it  may  not  be  wise  to 
use  water  below  70°  F.,  but  many  patients 
over  three  years  have  the  water  applied  in  the 
form  of  a  cold  douche  after  the  cleansing  bath, 
during  the  entire  twelve  months  at  the  tempera- 


Baths  113 

ture  at  which  it  runs  from  the  faucet.  In 
winter,  in  New  York  houses,  this  ranges  from 
50°  to  60°  F. 

In  giving  the  cold  douche  the  child  should 
stand  in  warm  water  covering  the  ankles.  The 
douche  may  be  used  in  the  form  of  a  spray 
or  shower  or  the  water  may  be  applied  by 
means  of  a  sponge  moistened  with  it  at  the 
desired  temperature.  The  head,  if  the  shower 
or  spray  is  used,  should  be  suitably  protected 
by  an  oil-skin  or  rubber  bathing  cap. 

After  the  cold  douche  there  should  be  a 
vigorous  friction  of  the  skin  with  a  rough 
towel.  If  there  is  not  a  quick  reaction,  if  the 
skin  does  not  become  warm  and  glowing, 
warmer  water  should  be  used.  So  also  with 
blueness  of  the  extremities  and  "goose  flesh"; 
use  water  less  cold,  but  do  not  discontinue  the 
douche. 

In  the  great  majority  of  homes  the  bathing 
of  the  children  can  be  carried  on  with  greater 
convenience  immediately  before  their  bed- 
time. The  child  should  receive  the  warm  bath 
and  the  cold  douche,  and  then,  in  night-clothes, 
a  warm  wrapper,  and  suitable  foot  covering,  he 
should  have  his  supper.  However,  if  this  time 
is  not  convenient,  he  may  be  given  the  evening 


ii4  Baths 

meal  at  5  130  or  6 130,  followed  in  one  hour 
by  the  bath  and  bed. 

Tub-baths  for  fever. — Place  the  child  in 
water  at  a  temperature  of  95°  F.  and  reduce 
to  75°  or  80°  F.  by  the  addition  of  ice  or 
cold  water.  The  duration  of  the  bath  should 
not  be  more  than  ten  minutes,  constant  fric- 
tion being  maintained  during  the  entire  proc- 
ess. 

Basin  bathing  for  fever. — Add  eight  ounces 
of  alcohol  to  a  quart  of  water  at  a  tempera- 
ture of  70°  F.  The  child  is  stripped  and 
covered  with  a  flannel  blanket,  and  the  entire 
body  sponged  with  this  solution  for  ten  or 
fifteen  minutes. 

Either  the  tub-bath  or  the  basin-bath  may 
be  used  by  the  mother  in  case  of  sudden  high 
fever — 104°  to  105°  F. — before  the  physician 
arrives.  She  should  be  so  instructed. 

Bathing  for  comfort  in  hot  weather. — The 
basin-bath  and  tub-bath  may  also  be  used  as 
a  means  of  relief  during  very  hot  weather. 
One  or  two  basin-baths  a  day,  with  a  tub- 
bath  at  bedtime  during  this  trying  season,  will 
give  the  child  much  relief,  and  help  him  to 
pass  safely  through  it.  The  very  young  feel 
the  extreme  heat  most  acutely,  and  endure  it 


Baths  115 

with  difficulty.  I  know  of  nothing  else  that 
will  give  a  restless,  uncomfortable,  heat-tor- 
mented child  such  a  refreshing  sleep  as  will 
a  cool  basin-bath. 

Mustard  bath. — A  mustard  bath  is  prepared 
by  adding  a  heaping  tablespoon ful  of  mustard 
to  six  gallons  of  warm  water.  The  mustard 
should  be  placed  in  a  small  muslin  bag  and 
placed  in  the  water.  One  of  the  uses  of  the 
mustard  bath  is  in  the  treatment  of  convul- 
sions ;  it  will  be  found  useful  also  for  nervous 
children  who  sleep  badly.  Two  or  three  min- 
utes in  the  mustard  water,  followed  by  a  quick 
rubbing  immediately  before  going  to  bed,  is 
oftentimes  all  that  will  be  required  to  induce 
refreshing  sleep. 

Brine  bath. — A  brine  bath — an  even  table- 
spoonful  of  salt  to  one  gallon  of  water — is  of 
great  service  with  very  delicate,  poorly 
nourished  children.  Its  action  is  that 
of  a  tonic.  If  the  child  is  thoroughly 
soaped  and  washed  with  plain  water,  and 
then  immersed  in  the  brine  bath,  no  further 
tubbing  is  necessary.  The  child  should  be 
kept  in  the  bath  for  five  or  ten  minutes, 
constant  friction  being  continued  during  the 
entire  time. 


n6  Baths 

Soda  bath. — The  soda  bath  is  of  some  ser- 
vice in  cases  of  prickly  heat  from  which  many 
children  suffer  during  the  summer.  A  table- 
spoonful  of  bicarbonate  of  soda  should  be 
added  to  each  half -gallon  of  water  used.  The 
temperature  of  the  water  should  be  that  to 
which  the  child  is  accustomed.  From  two  to 
four  minutes  in  the  water  suffices.  There 
should  be  little  or  no  friction  of  the  skin.  The 
child  should  be  dried  with  soft  towels. 

Bran  bath. — The  bran  bath  also  is  of  ser- 
vice in  prickly  heat.  One  cup  of  bran  is 
mixed  with  the  water  in  the  bath-tub  and 
the  same  method  employed  as  for  the  soda 
bath. 

Starch  bath. — The  starch  bath  also  is  useful 
in  prickly  heat.  One-half  cupful  of  powdered 
laundry  starch  is  mixed  with  the  water  in  the 
bath-tub,  and  the  same  method  employed  as 
for  the  soda  bath. 

Hot  bath. — Place  the  child  for  from  three 
to  five  minutes  in  water  which  has  been  raised 
to  a  temperature  of  105°  to  no°F.  Con- 
stant friction  of  the  extremities  is  maintained 
while  in  the  water.  Upon  removing  the  child 
from  the  water  wrap  him  quickly  in  a  warm 
blanket  and  put  him  in  a  warm  bed. 


Earache  n? 

EARACHE 

Infants  and  young  children  are  very  sus- 
ceptible to  attacks  of  earache.  They  usually 
occur  in  children  who  are  suffering  from  some 
inflammatory  condition  of  the  throat  or  nose. 
Such,  however,  is  not  necessarily  the  case.  I 
have  seen  earache  in  children  who  apparently 
were  in  perfect  health.  In  the  very  young  the 
only  symptoms  of  the  trouble  may  be  restless- 
ness, fever,  which  is  usually  present,  and  pain, 
which  is  manifested  by  crying.  I  have  re- 
peatedly seen  an  attack  so  severe  as  to  cause 
an  infant  to  shriek  with  pain,  without  any  sign 
to  locate  the  trouble.  An  older  child,  in  addi- 
tion to  the  above,  will  usually  raise  the  hand  to 
the  side  affected  or  point  to  the  painful  ear. 
The  child  usually  is  much  disturbed  if  the  ear 
is  touched  or  manipulated  in  any  way.  While 
severe  pain  is  the  rule  in  ear  disease,  it  may 
be  absent;  there  may  be  loss  of  appetite,  high 
fever,  and  restlessness  for  three  or  four  days 
with  no  other  sign  of  illness,  and  no  evidence 
whatever  of  pain,  when  suddenly  one  discovers 
a  yellowish  discharge  from  the  ear,  with  tem- 
porary or  permanent  relief  from  the  symptoms. 

Management. — In  case  of  an  attack  of  ear- 


n8  Earache 

ache,  dry  heat  is  of  much  service.  Rest  the 
ear  on  a  hot-water  bag,  or  apply  a  salt  bag, 
made  by  sewing  together  two  pieces  of  muslin 
about  three  by  five  inches  in  size  and  filling 
it  half  full  with  salt.  The  bag  and  contents 
are  then  pressed  flat,  heated,  and  applied  to 
the  ear,  the  salt  retaining  the  heat  for  a  long 
time.  Another  device  is  to  fill  the  finger  of 
an  old  glove  with  salt,  heat  it,  and  place  the 
tip  in  the  ear.  As  an  extra  precaution  the 
mother  or  nurse  should  first  test  it  in  her  own 
ear.  A  douche  at  110°  F.  may  also  be  of  con- 
siderable service  in  these  cases;  in  my  experi- 
ence, earache  is  best  relieved  by  this  means. 
The  child  should  be  pinned  in  a  sheet,  and  lie 
on  its  back,  with  its  head  on  a  level  with  or  a 
little  lower  than  the  body.  A  basin  protected 
with  a  towel  or  absorbent  cotton  is  placed 
under  the  ear.  One  assistant  is  required  to 
steady  the  head,  as  the  child  will  be  sure  to 
struggle.  The  douche  bag — an  ordinary  foun- 
tain syringe — should  be  held  not  more  than 
two  feet  above  the  child's  head.  From  one 
to  two  pints  of  sterile  water  may  be  needed. 
The  tip  of  the  syringe  is  placed  about  one- 
quarter  of  an  inch  from  the  orifice  of  the  canal 
and  the  water  is  allowed  to  flow  into  the  ear 


The  Care  of  the  Eyes      1 19 

until  the  child  is  relieved  or  until  the  bag  is 
empty.  In  giving  the  douche,  elevate  the  ear 
by  grasping  the  tip  with  the  fingers,  thereby 
widening  the  opening.  Such  a  douche  may  be 
repeated  every  hour  until  medical  aid  arrives. 
Earache  is  usually  due  to  the  presence  of 
pus  or  other  fluid  behind  the  drum  membrane. 
This  causes  pressure  within  the  ear  which  may 
require  a  slight  operation  for  its  relief. 

THE  CARE  OF  THE  EYES 

The  eyes  should  always  be  well  protected 
from  the  sunlight,  the  young  infant  never  be- 
ing allowed  to  lie  with  a  bright  light  from 
a  window  streaming  into  its  face. 

The  eyes  should  be  washed  once  daily  with 
plain  boiled  water.  A  piece  of  soft  old  linen 
should  be  used  and  immediately  burned.  Be- 
fore touching  the  eyes  for  any  purpose,  the 
hands  must  be  washed  with  hot  water  and 
soap. 

No  other  home  treatment  of  the  eye  is  al- 
lowable, however  slight  the  ailment.  The 
custom  of  putting  breast-milk  into  the  eyes 
cannot  be  too  strongly  condemned.  Teas 
of  various  kinds  and  proprietary  or  home- 


120  Dentition 

made  eye-washes  should  never  be  used.  Over 
90  per  cent,  of  the  cases  of  blindness  develop 
during  early  life,  due  to  an  infection  which  is 
neglected  or  badly  treated. 

DENTITION 

Much  has  been  written  about  the  process 
of  teething.  Nearly  all  the  ills  of  childhood, 
other  than  the  contagious  diseases,  have  been 
attributed  to  this  cause.  Not  only  the  laity, 
but  physicians,  are  often  inclined  to  attribute 
this  or  that  ailment  to  teething.  Many  a  diag- 
nostic puzzle  has  been  smothered  under  the 
diagnosis  of  dentition.  Observations  covering 
the  teething  period  of  several  thousand  children 
in  institution,  out-patient,  and  private  work, 
among  all  classes  and  conditions  of  children, 
have  taught  me  to  divide  teething  babies  into 
three  groups :  the  breast-fed,  the  well-man- 
aged bottle-fed,  the  badly  fed. 

The  breast-fed. — In  the  great  majority  of 
the  breast-fed,  the  teeth  appeared  at  the 
proper  time,  with  little  or  no  disturbance. 
Perhaps  there  was  a  period  of  irritability  and 
restlessness  for  a  few  days  before  the  teeth 
came  through.  In  many,  the  teeth  appeared 


Dentition  121 

without  the  slightest  inconvenience,  and  that 
a  tooth  had  been  cut  was  discovered  while 
washing  or  dressing  the  baby.  In  a  very  few 
breast-fed  babies  there  was  distinct  irritability 
and  restlessness,  with  fever  and  a  slight 
diarrhoea,  all  of  which  subsided  when  the 
teeth  appeared. 

The  well-managed  bottle-fed,  such  as  were 
given  cows'  milk,  properly  prepared  and  di- 
luted, teethed,  as  a  rule,  without  inconvenience. 
Some  showed  a  tendency  to  slight  gastro-intes- 
tinal  disturbance,  which  was  relieved  by  diet 
and  simple  medication.  The  cases  which  occa- 
sionally developed  severe  intestinal  disturbances 
were  those  which  cut  the  first  molars  or  several 
other  teeth  at  one  time  during  the  hot  weather. 
Such  infants  must  be  kept  on  a  very  light  diet 
until  the  teeth  are  through,  or  until  the  onset 
of  colder  weather. 

The  badly  fed. — These  were  nearly  all 
bottle-fed.  They  were  given  cows'  milk  im- 
properly prepared  or  at  too  frequent  intervals. 
Only  condensed  milk  and  the  proprietary  foods 
had  been  given  some  of  these  infants.  To  this 
class  belong  the  great  number  of  infants  who 
are  given  bread,  meat,  potatoes,  and  sweets 
before  the  digestive  organs  are  ready  for  such 


122  Dentition 

food.  It  is  these  badly  fed,  debilitated, 
rachitic  infants  who  are  said  to  "teeth  hard." 
They  teeth  late,  cut  several  teeth  at  one  time, 
and  have  attacks  of  convulsions,  diarrhoea,  and 
vomiting  during  the  teething  period.  There  is 
no  doubt  that  the  alimentary  tract  is  pre- 
disposed to  troubles  of  a  catarrhal  nature  dur- 
ing active  dentition.  If  the  baby  has  been 
properly  fed  and  is  in  fair  health,  this  tendency 
is  so  slight  that  it  probably  will  not  be  noticed. 
If,  on  the  other  hand,  the  digestive  tract  is 
weakened  from  abuse,  vomiting  and  diarrhoea 
often  result. 

The  influence  of  rachitis. — The  majority  of 
children  who  belong  to  the  third  group  are 
rachitic,  and  rickets  always  mean  enfeebled 
resisting  powers.  Rachitic  children  teeth  late. 
A  rachitic  boy  under  my  observation  cut  his 
first  tooth  during  the  ninth  month,  and  with 
the  eruption  of  this  tooth  and  with  each  of  the 
five  that  appeared  at  intervals  of  two  or  three 
weeks  during  the  next  five  months,  an  attack 
of  vomiting  and  diarrhoea  occurred,  each  at- 
tack subsiding  when  the  tooth  pierced  the 
gum. 

Complications. — Irritability  and  restlessness, 
slight  fever  and  gastro-intestinal  derange- 


Dentition  123 

ments,  were  the  only  unpleasant  effects  of 
dentition  in  any  of  my  patients  who  were  in 
fair  health.  The  irritability,  restlessness,  and 
fever  appeared  to  be  due  directly  to  dentition. 
Indirectly,  teething  may  be  a  factor  in  gastro- 
intestinal derangements.  The  process  may  be 
painful,  the  digestive  organs  fail  to  act 
properly,  and  trouble  follows.  I  have  never 
known  dentition  to  cause  bronchitis,  eczema, 
or  skin  eruptions  of  any  kind. 

Possible  dangers. — The  opinion  is  very 
general  among  the  ignorant,  that  bronchitis 
needs  no  treatment,  and  that  diarrhoea  is  bene- 
ficial during  the  teething  process.  These  be- 
liefs, equally  dangerous,  have  been  the  cause 
of  an  incalculable  amount  of  harm:  as  the  re- 
sult, many  lives  are  lost  yearly.  I  have  time 
and  again  seen  children  die  with  summer 
diarrhoea  who  were  brought  for  treatment 
when  no  hope  could  be  given.  The  mother 
had  been  told  and  believed  that  diarrhoea  was 
beneficial  to  the  teething  child,  and  that  if  the 
diarrhoea  were  stopped  the  child  would  be 
thrown  into  convulsions. 

Management. — When  the  form  of  a  tooth 
can  be  made  out  pressing  on  the  gum,  and  the 
child  is  fretful  and  feverish,  the  digestive 


i24  The  Teeth 

capacity  is  lessened,  as  previously  mentioned. 
When  such  is  the  case  the  nourishment  should 
be  temporarily  reduced  one-half  by  the  addi- 
tion of  boiled  water.  If  the  child  is  breast- 
fed, the  nursing  period  should  be  reduced  to 
five  or  six  minutes,  and  boiled  water  given  to 
drink  between  feedings.  If  a  tooth  is  trying 
to  force  its  way  through  a  thick,  resistant  gum, 
a  great  deal  of  pain  and  discomfort  will  be 
spared  the  child  if  the  tooth  is  assisted  in  its 
progress.  This  is  best  accomplished  by  the 
use  of  a  clean  towel,  which  is  placed  over  the 
finger  and  vigorous  friction  brought  to  bear 
over  the  sharp  edge  of  the  tooth.  It  is  quicker 
and  less  painful  than  lancing,  and  the  gum 
will  not  close  over  the  tooth. 

THE  TEETH 

Twenty  teeth  comprise  the  first  set.  In  the 
well  child  the  first  tooth  usually  appears  be- 
tween the  sixth  and  the  eighth  months;  the 
first  teeth  may,  however,  in  perfectly  normal 
cases,  come  earlier  or  much  later.  I  have 
known  well,  vigorous  children  who  did  not  get 
a  tooth  until  the  thirteenth  month.  The  first 
teeth  are  usually  the  two  lower  central  incisors ; 


The  Teeth  125 

generally  the  four  upper  incisors  and  the  two 
lower  lateral  incisors  appear  between  the  eighth 
and  the  tenth  months.  The  first  four  molars 
appear  between  the  twelfth  and  the  fifteenth 
months;  the  eye-  and  stomach-teeth  between 
the  eighteenth  and  the  twenty-fourth  months; 
the  four  posterior  molars  between  the  twenty- 
fourth  and  the  thirtieth  months.  This  regu- 
larity in  the  appearance  of  the  teeth  is  by  no 
means  constant  even  in  well  children.  I  have 
in  several  instances  seen  the  upper  lateral  in- 
cisors appear  first.  In  delayed  dentition  the 
teeth  are  very  apt  to  appear  irregularly. 

The  care  of  the  teeth. — As  soon  as  the  teeth 
appear  they  require  attention.  Until  the 
second  year  is  reached  the  mouth  should  be 
washed  out  at  least  twice  a  day  with  a  solu- 
tion of  boracic  acid — one  ounce  to  a  pint  of 
water.  This  can  best  be  done  by  means  of 
absorbent  cotton  wound  around  the  tips  of 
a  clean  index  finger  and  afterward  dipped  into 
the  solution,  when  it  should  be  applied  with 
gentle  friction  to  the  gums  and  teeth.  When 
a  child  is  two  years  old  it  is  well  to  begin  the 
use  of  a  soft  tooth-brush,  and  a  simple  tooth 
powder  composed  of  the  following  ingredi- 
ents: 


126  The  Teeth 

Precipitated  chalk,  I  ounce. 
Bicarbonate  of  soda,  I  drachm. 
Oil  of  wintergreen,  a  few  drops. 

The  child  should  also  be  instructed  early 
as  to  the  proper  use  of  a  quill  tooth-pick. 

The  milk-teeth  are  lost  between  the  sixth 
and  eighth  years.  They  should  not  decay  but 
fall  out  or  be  forced  out  by  the  second  set. 
The  teeth  of  every  child  over  two  years  of  age 
should  be  examined  by  a  dentist  every  six 
months.  If  cavities  are  discovered  in  the  first 
teeth  they  should  be  filled  with  a  soft  filling. 

The  permanent  teeth. — The  permanent  set 
comprises  thirty-two  teeth.  The  second  denti- 
tion begins  about  the  sixth  year,  and  is  usually 
completed  about  the  twentieth  year,  although  it 
may  be  delayed  several  years  later.  The  per- 
manent teeth  appear  in  somewhat  the  follow- 
ing order: 

First  molars sixth  year. 

Central  incisors sixth  to  seventh  year. 

Lateral  incisors seventh  to  eighth  year. 

First  bicuspids ninth  to  tenth  year. 

Second  bicuspids ninth  to  tenth  year. 

Canines eleventh  to  twelfth  year. 

Second  molars thirteenth  to  fifteenth  year. 

Third  molars after  the  eighteenth  year. 


The  Hair  127 

THE  HAIR 

Whether  the  child  should  wear  the  hair  long 
or  short  is  a  point  upon  which  the  doctor  is 
likely  to  give  unsought  advice.  There  are  two 
reasons  why  a  child's  hair  should  be  kept  short : 

1.  From  the  standpoint  of  comfort.     Dur- 
ing  the   hot   months    children   perspire   very 
freely  both  by  day  and  by  night.     The  heavy 
mass  of  hair  which  falls  about  the  neck  and 
shoulders  adds  greatly  to  the  warmth  and  dis- 
comfort.    I  find  that  many  children  with  long 
hair  are  poor  sleepers  and  are  irritable  and 
hard  to  please  when  awake.     In  winter  the 
child  is  very  apt  to  perspire  about  the  head 
and  neck  in  active  play,  and  runs  a  greater 
risk  from  exposure  than  if  the  excessive  per- 
spiration did  not  occur. 

2.  The  hair  should  be  kept  reasonably  short, 
because  then  the  scalp  can  be  kept  in  a  much 
healthier  condition,  and  a  much  better  growth 
of  hair  assured  in  later  life. 

NURSERY-MAIDS 

The  mother  who  can  afford  the  expense  of 
a  helper  should  never  take  entire  charge  of 


128  Nursery-Maids 

her  baby;  nor  should  she  share  this  duty  with 
the  maid  of  all  work  if  better  assistance  can 
be  secured.  The  child  requires  more  atten- 
tion than  any  one  person  should  bestow.  If 
one  person  is  constantly  in  charge  of  the  child 
it  will  either  be  neglected  or  the  health  of  that 
person  will  suffer,  and  her  services  will  be  less 
efficient.  Many  a  young  mother  has  sacri- 
ficed her  health  because  of  a  false  sense 
of  duty  in  this  respect.  The  close  con- 
finement in  itself  would  ruin  her  health  and 
make  her  prematurely  old.  The  children  that 
are  born  later  have  less  vigor,  are  more  sus- 
ceptible to  illness,  and  start  out  handicapped 
in  life  as  a  consequence.  The  constant  atten- 
tion of  the  mother  is  not  necessary;  in  fact,  it 
is  often  injurious  to  the  child.  She  is  apt  to 
handle  the  child  too  much,  to  over-entertain  it. 
A  bright  young  woman  should  be  secured  as 
soon  as  the  monthly  nurse  leaves,  to  assist  in 
the  care  of  the  child.  If  she  is  a  trained 
nursery-maid  who  has  had  previous  experience 
of  the  right  kind,  she  will  be  invaluable.  In 
case  a  trained  assistant  is  not  to  be  obtained, 
any  intelligent  young  woman  of  cleanly  habits, 
and  who  is  fond  of  children,  may  be  trained 
at  home  in  a  few  weeks. 


The  Trained  Nurse         129 

THE  TRAINED  NURSE 

If  possible,  a  trained  nurse  should  be  em- 
ployed in  every  severe  illness  of  childhood. 
She  may  alternate  with  the  mother  or  nursery- 
maid in  the  care  of  the  child.  If  the  case  is 
very  urgent,  two  trained  nurses  should  be 
employed.  The  nurse  must  never  be  expected 
to  work  for  more  than  twelve  consecutive 
hours.  A  tired  nurse  should  never  be  in  charge 
of  a  sick  baby. 

The  employment  of  a  trained  nurse  does 
not  mean  that  the  mother  may  not  perform 
many  little  offices  for  the  patient,  but  the 
trained  nurse  should  be  in  charge,  and  her 
opinions  respected. 

Many  an  excellent  mother  makes  a  very  poor 
nurse  for  her  own  child  during  a  severe  illness. 
Her  great  interest  and  anxiety  impair  her 
judgment.  She  is  apt  to  become  con- 
fused and  fail  to  meet  emergencies.  A 
mother  who  is  useless  for  a  like  office 
in  her  own  household  oftentimes  makes 
an  excellent  nurse  for  her  friend's  child. 
The  mother  in  the  capacity  of  a  nurse 
for  her  own  infant  is  apt  to  fail  under  some  of 


130        The  Trained  Nurse 

the  following  conditions :  She  is  inclined  to 
put  more  clothing  on  the  baby  than  the  doctor 
advised.  If  a  window  is  the  means  of  ventila- 
tion, she  has  a  strong  inclination  to  close  it  a 
little  beyond  the  point  which  the  physician 
marked  with  a  lead-pencil.  The  temperature 
of  the  sickroom  is  often  kept  higher  than  is 
good  for  the  baby.  Offices,  the  performance 
of  which  cause  the  child  discomfort,  are  often 
not  thoroughly  attended  to,  such  as  washing 
the  eyes,  sponging  off  the  patient  in  fever, 
syringing  the  ears,  and  adhering  to  a  greatly 
restricted  diet.  These,  and  a  few  like  offenses, 
are  pardonable  in  the  mother,  but  they  show 
us  that  in  a  severe  illness  trained  help  is  indis- 
pensable. Further,  I  am  very  sorry  to  say  that 
sometimes  influences  against  carrying  out  the 
physician's  directions  in  important  particulars 
are  successfully  brought  to  bear  upon  the 
mother  by  well-meaning  relatives  and  friends 
who  possess  no  knowledge  whatever  of  the  ill- 
ness in  question. 

ADENOIDS 

Adenoids  are  tumor-like  growths  that  de- 
velop at  the  junction  of  the  upper  portion  of 


Adenoids 


the  posterior  pharyngeal  wall  and  the  vault  of 
the  pharynx.  They  may  simply  cover  the  sur- 
face of  the  parts  in  a  spongy  layer  or  they  may 
fill  the  entire  naso-pharyngeal  space,  com- 
pletely blocking  the  passage  from  the  nose  to 
the  throat.  They  are  not  to  be  considered  as 
new  growths,  but  rather  as  hypertrophies,  or 
overgrowths,  of  the  mucous  glands  and  tissues 
of  the  parts.  They  may  vary  in  size  from  a 
flaxseed  to  a  walnut.  Among  the  causes  of 
adenoids  may  be  mentioned  the  use  of  the 
"pacifier"  in  infancy,  repeated  "colds"  in  the 
head,  breathing  the  dust-laden  air  of  our  large 
cities,  malnutrition,  and  unhygienic  living. 
While  the  taking  of  cold  is  a  factor  in  the  de- 
velopment of  adenoids,  my  observation  is  that 
predisposition  plays  an  important  part.  Many 
children  have  a  tendency  to  glandular  enlarge- 
ment ;  in  fact,  in  this  country,  a  large  percent- 
age of  the  children  under  ten  years  of  age  have 
adenoids.  In  a  child  under  two  years  of  age 
the  naso-pharyngeal  space  is  a  very  narrow 
slit;  and  since  the  majority  of  children  up  to 
the  eighteenth  month  of  life  are  sucking  on 
something  the  greater  part  of  their  waking 
hours,  the  soft  palate  is  forced  back  against 
the  posterior  pharyngeal  wall,  interfering  with 


132  Adenoids 

the  drainage  of  the  parts,  and  on  account  of 
the  friction  of  the  opposed  surfaces  congestion 
and  irritation  follow,  resulting  finally  in  a 
general  hypertrophy. 

Age. — Very  young  children  may  have 
adenoids.  The  youngest  patient  that  I  have 
operated  upon  was  eight  months  old.  The 
majority  of  cases  occur  in  children  from 
eighteen  months  to  six  years  of  age.  A  slight 
amount  of  adenoid  growth  may  cause  no  symp- 
toms. A  few  summers  ago  I  examined  the 
throats  of  forty  children  between  the  ages  of 
two  and  five  years,  who  came  for  treatment 
for  other  conditions.  In  thirty-seven,  ade- 
noids were  present.  In  twelve,  operation  was 
advised,  and  in  five,  operation  was  performed. 
In  fifteen  the  growths  were  not  sufficiently 
large  to  justify  operation  in  the  absence  of 
annoying  or  dangerous  symptoms. 

The  presence  of  adenoids  is  perhaps  most 
often  manifested  by  symptoms  of  chronic  cold 
in  the  head.  There  is  a  great  deal  of  discharge 
from  the  nose.  The  child  has  snuffles  all  win- 
ter. During  summer  there  is  little  if  any 
trouble.  The  child  is  said  to  take  cold  easily. 
The  slightest  exposure  will  cause  a  running  at 
the  nose.  Cough  is  often  associated  with  the 


Adenoids  133 

nasal  discharge,  or  it  may  follow  it.  The 
cough  is  worse  at  night;  in  fact,  it  often  is  not 
noticed  until  the  child  goes  to  bed.  Such  a 
cough  was  formerly  known  as  "the  nervous 
cough"  or  "the  stomach  cough." 

Mouth-breathing. — If  the  growths  are  large, 
we  have  mouth-breathing  added  to  the  other 
symptoms.  The  child  breathes  through  the 
mouth  both  day  and  night  for  the  reason  that 
the  breathing  space  through  the  nose  is  choked. 
The  night  mouth-breathing  gives  rise  to  snor- 
ing; some  of  these  children  snore  like  adults. 
Almost  every  snoring  child  will  be  found  to 
have  either  adenoids  or  enlarged  tonsils,  or 
both. 

In  advanced  cases  the  appearance  of  the  face 
of  the  patient  is  characteristic.  The  habitual 
open  mouth  gives  the  face  a  stupid  expression. 
In  fact,  such  children  are  apt  to  be  mentally 
dull.  The  nostrils  are  small  and  pinched.  The 
upper  lip  is  usually  thickened.  The  voice  is 
also  affected;  there  is  a  decided  nasal  twang, 
and  articulation  is  sometimes  impaired.  The 
child  has  trouble  in  blowing  his  nose.  Occa- 
sionally adenoids  are  the  cause  of  very  severe 
nosebleed.  In  a  small  proportion  of  the  cases 
hearing  is  impaired.  Bed-wetting  may  be  due 


134  Enlarged  Tonsils 

to  adenoids.  Recently  a  writer  reported  seven 
cases  of  inveterate  bed-wetters,  all  cured  by 
the  removal  of  the  adenoids.  Children  with 
adenoids  are  more  susceptible  to  diphtheria, 
and  if  they  contract  the  disease  it  is  apt  to  be 
more  severe.  For  adenoids  of  any  degree  of 
severity,  complete  removal  is  the  only  treat- 
ment. Sprays  and  the  various  local  applica- 
tions are  absolutely  worthless.  The  operation 
is  practically  without  danger. 

ENLARGED  TONSILS 

Chronic  enlargement  of  the  tonsils  is  almost 
always  associated  with  adenoids  and  is  re- 
sponsible in  a  degree  for  their  presence.  We 
see  many  cases  of  adenoids,  however,  in  which 
there  is  no  tonsillar  enlargement.  Predisposi- 
tion and  repeated  attacks  of  acute  tonsillitis 
lead  to  chronic  enlargement  of  the  tonsils. 
Enlarged  tonsils,  when  associated  with  ade- 
noids, do  not  change  the  character  of  the  symp- 
toms of  adenoids  except  to  aggravate  them; 
therefore  they  should  be  removed  as  well  as 
the  adenoids.  All  other  treatment  in  young 
children  is  useless.  The  operation  in  skilful 
hands  may  be  said  to  be  practically  without 
danger.  Parents  always  dread  the  operation, 


Milk  in  Infants'  Breasts     135 

but  the  relief  afforded  the  suffering  child,  and 
the  knowledge  that  a  serious  obstacle  to  the 
child's  growth  and  development  has  been  re- 
moved, will  repay  them  for  their  hours  of 
anxiety.  Gargles  and  sprays  are  of  little  or 
no  value  in  chronic  enlargement  of  the  tonsils. 

MILK  IN  INFANTS'  BREASTS 

It  is  not  at  all  uncommon  for  an  infant's 
breasts,  at  birth,  to  contain  a  substance  resem- 
bling milk.  When  this  occurs,  the  breasts  are 
to  be  left  alone  and  the  milk  will  disappear.  It 
is  quite  a  common  belief  among  hospital  and 
dispensary  patients  that  the  milk  should  be 
pressed  out.  This  is  very  wrong.  In  two 
cases  I  have  known  abscesses  to  develop  after 
this  treatment  by  a  midwife,  and  in  one  case 
the  child  nearly  lost  its  life. 

TEMPERATURE,  AND  HOW  TO 
TAKE  IT 

The  normal  rectal  temperature  of  an  infant 
varies  between  98.5°  and  99.5°  F.  The  tem- 
perature should  be  taken  in  the  rectum.  The 
mouth  is  impossible,  the  groin  and  axilla  ab- 
solutely unreliable.  The  child  should  lie  on 


136  Appetite 

its  stomach  either  in  its  bed  or  across  the 
nurse's  lap.  Both  the  anus  and  the  bulb  of 
the  thermometer  should  be  well  oiled.  The 
bulb  is  passed  into  the  rectum  so  that  the  mer- 
cury cannot  be  seen  and  allowed  to  remain  two 
minutes.  If  the  child  kicks  or  struggles  some 
one  should  hold  its  legs.  Mothers  are  often 
disturbed  because  of  a  persistence  of  the  tem- 
perature between  99.5°  and  100.5°  F.  While 
such  a  degree  cannot  be  considered  normal,  it 
does  not  follow  that  it  is  of  any  consequence. 
This  slight  elevation  may  follow  the  acute  ill- 
nesses such  as  grippe,  pneumonia,  and  scarlet 
fever,  and  may  continue  for  weeks,  without 
any  harm  resulting.  Nervous,  irritable  infants 
will  often  range  at  100°  F.  for  weeks  at  a  time. 
In  like  manner  children  who  are  stimulated  by 
playing  with  older  children  or  with  adults  will 
often  develop  a  rise  in  temperature  which  sub- 
sides as  soon  as  the  cause  is  removed. 

The  thermometer  should  be  washed  with  a 
one-per-cent.  solution  of  carbolic  acid  or  alco- 
hol after  using. 

APPETITE 

It  may  be  safely  said  that  a  well,  vigorous 
child  is  a  hungry  child,  and  nearly  every  child 


Appetite  137 

may  be  made  thoroughly  hungry  three  times 
a  day  by  suitable  food  at  proper  intervals.  The 
children  who  come  under  my  care  for  poor 
appetite,  without  evidence  of  disease  to  account 
for  it,  are,  almost  without  exception,  improp- 
erly fed.  They  are  often  given  unsuitable 
food  at  meal-time,  when  they  are  loaded  down 
with  sweets  and  pastries;  but  the  chief  error 
is  eating  between  meals.  This  habit  has  ruined 
more  appetites  and  has  been  the  cause  of  more 
stomach  disorders  than  any  other  one  factor. 
It  is  surprising  what  a  large  amount  of  candy, 
sweet  crackers,  and  the  like  are  disposed  of 
in  many  households.  Every  year  I  am  called 
upon  to  treat  cases  of  loss  of  appetite  in  "run- 
abouts" from  eighteen  months  to  three  years 
of  age,  who  have  what  I  have  designated  the 
milk  habit.  These  children  drink  from  five 
to  six  pints  of  milk  a  day,  and  refuse  all  other 
food.  The  milk  satisfies  the  appetite  but  does 
not  furnish  the  nourishment  required  for  the 
rapid  growth  that  takes  place  at  this  time,  and 
the  child  in  consequence  suffers  from  malnu- 
trition. He  is  pale,  thin,  and  sallow  in  appear- 
ance, the  sleep  is  poor,  and  the  child  is  irritable 
and  hard  to  please.  We  also  see  children  at 
this  age  who  suffer  from  improper  nutrition 


138  Appetite 

on  account  of  too  restricted  a  diet.  They  take 
other  food  than  milk,  but  not  in  sufficient  quan- 
tity or  variety.  Some  will  refuse  all  kinds  of 
vegetables,  others  will  refuse  all  kinds  but  one 
or  two ;  some  will  not  take  stewed  fruit ;  others 
will  not  touch  meat  or  eggs,  no  matter  how 
they  may  be  prepared;  some  will  take  but  one 
cereal,  others  will  refuse  cereals  altogether. 
The  child's  whims  in  these  respects  must  never 
be  catered  to.  He  is  to  take  what  is  placed 
before  him  or  go  without  until  the  next  meal. 
Likes  and  dislikes  for  various  articles  of  diet 
are  largely  a  matter  of  education,  and  the 
child  may,  and  should,  be  taught  to  eat  every- 
thing that  is  good  for  him.  A  little  firmness 
in  compelling  him  to  go  hungry  for  a  few 
hours  will  soon  do  away  with  any  childish 
fancy,  which  may  be  the  cause  of  considerable 
harm.  These  children  are  rapidly  growing, 
and  for  proper  growth  and  development  re- 
quire a  mixed  diet.  If  the  child  is  wedded  to 
milk  and  refuses  everything  else,  the  milk  must 
temporarily  be  discontinued.  Some  children 
with  a  poor  appetite  for  solids  will  drink  a 
glass  or  two  of  milk  at  the  commencement  of 
a  meal.  This  satisfies  the  appetite  for  the  time 
and  nothing  more  will  be  taken.  With  such 


Appetite  139 

children  the  milk  must  be  kept  out  of  sight 
until  the  meal  is  completed,  when  one-half  pint 
may  be  given. 

I  have  treated  quite  a  number  of  cases  of 
poor  appetite  and  milk  appetite  in  children 
otherwise  well,  in  the  following  manner:  The 
child  is  undressed  and  placed  in  bed  and  put 
under  the  care  of  one  person  as  though  he  were 
very  ill.  The  object  in  placing  the  patient  in 
bed  is  to  prevent  his  getting  food  other  than 
that  ordered.  He  is  allowed  water  to  drink  in 
plenty.  For  the  first  day  he  is  given  four 
ounces  of  plain  chicken  or  mutton  broth  every 
three  hours.  The  second  day  he  receives  six 
to  eight  ounces  of  the  broth  at  three-hour  in- 
tervals. On  the  third  day  he  is  usually  raven- 
ously hungry  and  he  is  then  given  three  or  four 
good  meals,  when,  if  he  has  any  special  dislike 
for  any  article  of  diet,  that  is  included  in  the 
first  meal.  In  such  cases  it  is  surprising  with 
what  favor  the  formerly  despised  cereal,  meat, 
egg,  <5r  vegetable  will  be  looked  upon,  and  it 
will  thereafter  have  a  cherished  place  in  the 
child's  heart.  Some  mothers  will  not  be  a 
party  to  such  heartless  treatment,  as  they  are 
inclined  to  call  it,  but  this  is  a  wrong  view  to 
take  of  it.  A  complete  change  of  diet  for  a 


Appetite 

day  or  two  would  often  be  of  benefit  to  all  of 
us.  With  the  child  the  advantage  derived 
from  thus  learning  to  enjoy  a  mixed  diet 
will  favorably  influence  his  health  for  the 
rest  of  his  life.  Change  of  climate,  fresh 
air,  out-of-door  exercise,  suitable  food  at 
regular  intervals — all  favorably  affect  the 
appetite. 

Another  effective  means  of  combating  the 
habitually  poor  appetite  at  any  age  after  the 
eighteenth  month,  is,  three  meals  a  day  at  con- 
siderable intervals.  The  first  meal  at  7 130,  the 
second  at  12.30,  the  third  at  5  130.  Absolutely 
nothing  but  water  is  to  be  given  between 
meals.  A  vast  number  of  poor  feeders  have 
been  changed  to  normally  hungry  children  by 
this  means. 

Children  who  over-exert  themselves  at 
school  or  at  play  or  who  are  easily  excited  and 
have  plenty  of  opportunity  for  excitement 
often  suffer  from  loss  of  appetite.  The  man- 
agement of  these  cases  is  to  remove  the  source 
of  the  trouble,  whatever  it  may  be.  An  ex- 
cellent means  of  bringing  these  children  to  a 
normal  condition  is  an  enforced  rest  for 
one  and  one-half  hours  after  the  noon-day 
meal. 


Habits 

HABITS 


THE  PACIFIER;    EAR-PULLING;    MASTUR- 
BATION 

Babies  acquire  habits  most  easily  and  at  a 
very  early  age.  Whether  the  habits  are  good 
or  bad  depends  more  upon  the  child's  attend- 
ants than  upon  the  child  itself.  If  properly 
trained  —  and  the  training  must  begin  at  birth 
—  a  baby  will  acquire  the  habit  of  taking  his 
food  at  regular  intervals  by  day  and  by  night, 
and  he  will  also  acquire  the  habit  of  going  to 
sleep  and  waking  at  regular  intervals.  As  a 
result  of  a  careful  regime  regarding  feeding, 
sleep,  bathing,  and  airing,  and  the  performance 
of  its  various  functions  at  stated  times  every 
day  the  baby  will  soon  develop  into  a  '  'little 
machine,"  as  one  mother  called  her  babe.  Such 
a  child  causes  no  trouble  and  thrives  far  better 
than  one  who  is  fed  every  time  he  cries,  day 
or  night.  A  baby  that  requires  constant  enter- 
taining when  awake,  and  that  sleeps  only  when 
exhausted,  usually  has  another  bad  habit,  —  that 
of  being  held  constantly  in  arms.  A  baby 
should  be  handled  very  little,  —  just  enough  to 
give  it  evercise.  It  will  learn  to  amuse  itself 
at  a  very  early  age  if  given  an  opportunity. 


142  Habits 

The  "pacifier"  habit — the  habit  of  sucking 
a  rubber  nipple — is  an  inexcusable  piece  of 
folly  for  which  the  mother  or  nurse  is  directly 
responsible.  The  habit  when  formed  is  most 
difficult  to  give  up.  The  use  of  the  "pacifier," 
thumb-sucking,  finger-sucking,  etc.,  make 
thick,  boggy  lips,  on  account  of  the  exercise  to 
which  the  parts  are  subjected.  They  cause  an 
outward  bulging  of  the  teeth  and  a  narrowing 
of  the  jaws,  which  are  not  conducive  to  per- 
sonal attractiveness.  Nature  has  not  been  so 
lavish  of  her  gifts  to  the  great  majority  of 
mankind  that  they  can  afford  to  trifle  with  her 
handiwork.  Furthermore,  the  ' 'pacifier"  is 
often  a  menace  to  health.  If  there  are  two 
or  three  young  children  in  the  family  it  is  fre- 
quently passed  around  without  other  means  of 
cleansing  than  being  drawn  a  couple  of  times 
across  the  nurse's  sleeve.  This  novel  method 
of  disinfecting  the  "pacifier"  may  be  seen  in 
actual  use  in  the  Park  any  pleasant  day,  and  I 
have  often  seen  the  mother  or  nurse  moisten 
the  "pacifier"  with  her  own  lips  before  giving 
it  to  the  child.  I  have  seen  young  children 
fight  for  the  "pacifier,"  one  taking  it  from 
the  mouth  of  another !  It  may  readily  be  con- 
ceived what  a  boundless  source  of  harm  this 


Habits 


little  instrument  may  be,  when  every  sort  of 
disease  known  to  childhood  may  be  trans- 
ferred by  it.  Thus  it  may  act  as  a  means  of 
transmitting  tuberculosis,  syphilis,  diphtheria, 
and  many  other  ail- 
ments of  minor 
importance.  In 
those  with  a  ten- 
dency to  vomit 
readily,  the  sucking 
habit  will  aid  ma- 
terially in  continu- 
ing the  disorder. 

Adenoids,  r  e  - 
ferred  to  in  another 
chapter,  are  often 
the  result  of  thumb- 
sucking  or  the  use 
of  the  "pacifier."  The  pressure  exerted  in 
sucking  forces  the  soft  palate  against  the  pos- 
terior pharyngeal  wall;  this  irritates  and  stim- 
ulates the  glands  of  the  part,  which  in  time 
enlarge,  and  adenoids  develop. 

Children,  at  any  age,  suffering  from  aggra- 
vated malnutrition  will  never  thrive  while  they 
practice  the  thumb,  finger  or  hand  sucking 
habit. 


FIG.  7.        THE  HAND-I-HOLD   MIT 


J44  Habits 

To  break  the  child  of  the  "pacifier"  habit, 
burn  the  "pacifier"  and  do  not  buy  another, 
as  is  sometimes  done.  For  thumb-sucking  and 
finger-sucking,  bandage  the  hands  and  moisten 
the  bandage  occasionally  with  a  solution  of 
quinine. 

The  "Hand-I-Hold  Mit"  (Fig.  7)  is  a  use- 
ful means  in  breaking  the  habit.  The  size 
varies  according  to  the  age  of  the  child.  The 
"Hund-I-Hold  Mit"  may  be  obtained  at 
Spangenberg,  82nd  Street  and  Columbus 
Avenue,  New  York  City. 

A  few  children  develop  the  ear-pulling 
habit.  It  is  always  one  ear  which  receives  at- 
tention. Sometimes  it  is  the  lobe  and  some- 
times the  upper  portion.  The  child  pulls  on 
the  ear  the  greater  portion  of  its  waking  hours. 
As  a  result  of  this  practice,  I  have  seen  ears 
drawn  entirely  out  of  shape.  Bandaging  the 
hands  so  that  the  fingers  can  not  be  used  to 
grasp  the  ear  is  the  best  means  of  breaking  the 
habit.  The  "Hand-I-Hold  Mit"  may  also  be 
used  with  advantage. 

Occasionally  children  are  met  with  who 
have  a  mania  for  placing  foreign  bodies  in  the 
nose  and  ear.  Shoe  buttons  are  the  favorites, 
although  beans,  pieces  of  coal,  pebbles,  and 


Habits  145 

various  other  kinds  of  buttons  serve  the  pur- 
pose when  shoe  buttons  are  scarce.  The  habit 
is  best  controlled  by  a  vigorous  spanking  fol- 
lowing each  offence. 

Masturbation  is  one  of  the  most  injurious 
of  habits.  It  consist  in  an  irritation  of  the 
genitals  by  manipulation,  by  leg-rubbing,  or 
by  pressing  the  parts  against  some  pointed 
object.  Under  the  age  of  six  years  mastur- 
bation is  more  common  in  girls  than  in  boys. 
My  youngest  patient  was  a  girl  only  six  months 
old.  If  the  habit  is  not  detected,  masturbation 
may  be  practiced  for  a  long  time  and  repeated 
many  times  a  day.  As  a  result,  the  child  be- 
comes irritable,  loses  sleep  and  weight,  and  is 
transformed  into  a  condition  of  mental  and 
physical  exhaustion. 

The  formation  of  habits  and  their  cor- 
rection rests  largely  with  the  mother  or  at- 
tendant. Considerable  stability  is  necessary 
for  the  correction  of  a  bad  habit,  or  the  forma- 
tion of  a  good  one.  It  means  several  prolonged 
crying  attacks  on  the  part  of  the  child  and  per- 
haps two  or  three  wakeful  nights. 

Management. — To  cure  the  habit  of  mastur- 
bation, if  the  child  is  under  eighteen  months 
of  age,  the  hands  may  be  bandaged,  or,  what 


i46        The  Normal  Throat 

is  better,  a  piece  of  tape  may  be  fastened  around 
each  wrist  and  tied  together  at  the  back  of  the 
neck,  making  all  secure  with  a  safety-pin.  The 
pieces  of  tape  should  be  of  sufficient  length  to 
allow  the  child  free  movement  of  the  hands, 
but  not  long  enough  to  allow  them  to  come  in 
contact  with  the  genitals. 

Leg-rubbing  is  more  frequently  seen  in  very 
young  girl  babies.  In  such  cases  the  wearing 
of  a  thick  napkin  or  of  two  napkins  will  usu- 
ally prevent  the  practice.  In  some  obstinate 
cases  of  leg-rubbing  in  older  girls  I  have  used 
a  "knee  crutch"  with  decided  success.  In 
children  over  two  years  of  age,  constant  watch- 
fulness and  vigorous  punishment  for  each  of- 
fense, combined  with  medical  treatment,  will 
cure  most  cases,  although  with  some  much 
difficulty  will  be  experienced. 

The  practice  must  be  prevented  and  the 
genitals  brought  to  a  normal  condition,  when 
the  patient  will  soon  forget  the  indulgence. 

THE  NORMAL  THROAT 

Every  mother  should  learn  the  appearance 
of  the  healthy  throat,  and  every  child  should 
be  accustomed  to  throat  examination.  It  will 


How  to  Examine  the  Throat  147 

soon  learn  that  no  harm  is  intended  and  force 
will  not  be  required.  The  family  physician 
should  demonstrate  to  the  mother  the  color 
of  the  normal  mucous  membrane,  and  the  size 
and  appearance  of  the  tonsils  in  health.  By 
knowing  the  normal  throat  she  will  be  able  to 
recognize  inflammation,  swelling,  and  exuda- 
tion in  the  form  of  the  cheesy  dots  seen  in  ton- 
sillitis, and  the  membrane  in  diphtheria.  With 
the  first  appearance  of  exudation  of  any  kind, 
medical  aid  should  be  summoned.  No  chances 
should  be  taken  with  these  cases.  I  know  of 
fathers  and  mothers  who  will  never  cease  to 
regret  that  they  did  not  appreciate  the  dangers 
of  temporizing  with  what  they  considered 
a  "cankerous  sore  throat."  Diphtheria  is 
most  insidious  in  its  onset  and  a  sore  throat 
should  never  be  neglected. 

HOW  TO  EXAMINE  THE  THROAT 
(See  Fig.  8.) 

In  order  to  examine  a  baby's  throat  quickly 
and  thoroughly  the  child  must  be  held  in  front 
of  and  at  the  right  side  of  the  attendant,  sup- 
ported by  the  attendant's  left  arm  under  the 
buttocks;  the  right  arm,  which  is  thus  left 


i48  How  to  Examine  the  Throat 

free,  is  passed  around  the  child,  binding  its 
arms  to  its  sides.  The  child's  head  rests  upon 
the  right  shoulder  of  the  attendant. 

The  mother  places  her  left  hand  on  the 
child's  head  to  steady  it  and  with  tongue  de- 
pressor or  teaspoon  in  her  right  hand  she 


FIG.    8.      THE    THROAT   EXAMINATION 

presses  down  the  tongue,  and,  with  the  child 
under  perfect  control,  she  brings  into  view 
the  parts  that  are  to  be  examined.  The  most 
satisfactory  view  can  be  obtained  by  daylight 
before  a  window.  If  the  examination  is  made 
in  the  evening,  a  lamp  or  taper  held  by  a  third 


Sprue  and  Thrush         149 

party,  a  trifle  above  and  behind  the  mother's 
right  shoulder,  will  furnish  a  satisfactory 
illumination. 

SPRUE  AND  THRUSH 

Thrush  consists  of  a  parasitic  growth  which 
appears  on  the  mucous  membrane  of  the  mouth 
in  young  infants.  The  disease  makes  its  ap- 
pearance in  the  form  of  small  white  masses 
about  the  size  of  a  pinhead.  The  tongue  and 
the  inner  side  of  the  cheeks  are  favorite  sites 
for  the  growth,  although  in  severe  cases  the 
entire  buccal  cavity  may  be  studded  with  it, 
causing  it  to  look  as  though  finely  curdled  milk 
had  been  scattered  over  the  surface.  The 
growth  is  firmly  adherent,  and  if  removed 
forcibly,  slight  bleeding  results.  It  is  usually 
associated  with  uncleanliness,  and  occurs,  as 
a  rule,  in  weakly  and  marasmic  nurslings  and 
in  the  bottle-fed,  more  frequently  in  the  latter. 
It  is  rarely  seen  after  the  sixth  month. 

In  an  infant  with  sprue,  there  is  evidence 
of  much  pain  and  discomfort  while  nursing  or 
while  feeding  from  a  bottle.  The  disease  is 
not  contagious.  The  average  case  may  easily 
be  cured  in  a  week,  if  the  directions  for  the 
treatment  are  carefully  carried  out.  Active 


Sprue  and  Thrush 

gastro-enteric  'disturbances,  such  as  vomiting 
and  diarrhoea,  may  be  associated  with  sprue, 
but  it  is  not  the  rule.  Time  and  again  I  have 
seen  cases  of  sprue  in  which  there  were  abso- 
lutely no  other  signs  of  the  disease  aside  from 
the  characteristic  mouth  lesions  and  the  refusal 
of  food. 

If  the  means  of  prophylaxis,  which  will  be 
suggested,  are  used  as  the  daily  routine,  the 
disease  will  never  appear. 

Sprue  in  the  breast-fed. — If  breast-fed,  the 
mother's  nipples  must  be  washed  with  a  satu- 
rated solution  of  boric  acid,  and  moistened 
with  alcohol,  diluted  one-half,  which  is  al- 
lowed to  evaporate  before  each  nursing.  If 
bottle-fed,  the  nipple  and  bottle  should  be  boiled 
after  each  nursing,  the  nipple  turned  inside 
out  and  scrubbed  with  borax  water — one  ounce 
of  borax  to  a  pint  of  water. 

The  mouth  toilet. — Whether  breast-fed  or 
bottle-fed,  the  mouth  should  be  washed  with 
a  saturated  solution  of  boric  acid  after  each 
nursing.  For  this  purpose  a  generous  amount 
of  absorbent  cotton  is  loosely  wrapped  around 
the  clean  index-finger  of  the  mother  or  nurse. 
This  is  placed  in  the  cold  solution,  and  with- 
out pressing  out  the  water  the  finger  is  intro- 


Stomatitis,  or  Sore  Mouth   151 

duced  into  the  child's  mouth,  and,  in  cases  of 
sprue,  brought  gently  in  contact  with  the  dis- 
eased parts,  first  with  one  side  and  then  with 
the  other,  being  pressed  upon  the  tongue  and 
under  the  tongue.  It  is  well  to  have  the  child 
rest  on  its  side  or  stomach  so  that  the  fluid 
which  is  pressed  out  by  the  manipulation  of  the 
cotton  against  the  cheeks  and  jaws  can  readily 
escape  from  the  mouth.  The  washing,  which 
really  amounts  to  an  irrigation,  can  be  done 
in  a  few  seconds,  without  the  slightest  danger 
of  abrading  the  epithelium. 

Internal  medication  is  no  value  in  sprue  ex- 
cept in  correcting  any  intestinal  derangement 
that  may  exist,  with  a  view  to  improving  the 
general  condition.  If  the  bottle  or  breast  is 
refused,  spoon-feeding  for  a  few  days  may 
be  necessary,  and  will  hasten  a  cure.  If  the 
child  is  nursed,  the  mother's  milk  may  be 
drawn  with  a  breast-pump  (see  page  49),  or 
pressed  out  with  the  fingers,  and  fed  to  the 
child.  The  domestic  remedy,  honey  and  borax, 
should  not  be  used  in  any  of  the  inflammatory 
diseases  of  the  mouth  in  children. 

STOMATITIS,    OR    SORE    MOUTH 
There  are  three  varieties  of  this  disorder — 


i52   Stomatitis,  or  Sore  Mouth 

the  catarrhal,  the  aphthous,  and  the  ulcerative. 

In  the  catarrhal  form  there  is  redness  of 
the  gums  with  excessive  secretion  of  saliva. 

In  aphthous  stomatitis,  distinct  grayish- 
white  plaques  will  be  noticed  on  the  inner 
side  of  the  cheek  and  under  surface  of  the 
tongue,  varying  in  size  from  a  pinhead  to  a 
split  pea. 

Ulcerative  stomatitis  is  the  most  serious 
disease  of  the  three.  It  may  occur  during 
serious  illness,  but  in  most  instances  it  occurs 
independently.  There  is  a  general  conges- 
tion of  the  mucous  membrane  with  the  secre- 
tion of  a  great  deal  of  saliva.  Its  distinguish- 
ing point,  however,  is  the  line  of  ulceration 
which  forms  on  the  border  of  the  gum  at  its 
junction  with  the  teeth.  The  ulceration  may 
be  so  severe  as  to  cause  a  loosening  and  fall- 
ing out  of  the  teeth.  The  breath  is  often 
very  foul,  and  the  gums  bleed  at  the  slightest 
touch. 

Lack  of  cleanliness  plays  a  large  part  in 
causing  sore  mouth.  Unclean  feeding  appa- 
ratus, the  use  of  the  "pacifier,"  and  the  custom 
of  allowing  a  baby  to  put  into  its  mouth  every- 
thing within  reach  account  for  a  majority  of 
the  cases. 


Taking  Cold  153 

The  symptoms  are  fever,  loss  of  appetite, 
and  evidences  of  much  discomfort  when  the 
child  attempts  to  eat.  In  many  cases  of  the 
ulcerative  form  there  is  high  fever  and  greater 
prostration  than  one  would  think  possible. 

The  prevention  and  treatment  are  the  same 
— cleanliness.  The  sore  mouth  should  be 
washed  with  a  saturated  solution  of  boric  acid 
after  each  feeding,  using  absorbent  cotton, 
which  is  wrapped  around  the  index  finger.  The 
cotton  is  saturated  with  the  solution  and  gently 
brought  into  contact  with  the  diseased  surface. 
Force  must  not  be  used  in  these  cases,  as  more 
damage  than  benefit  will  result  if  the  tissues 
are  lacerated.  In  the  ulcerative  form  internal 
treatment  is  required  in  addition  to  the  local 
means  suggested.  Every  case  of  ulcerative 
stomatitis  should  be  seen,  at  least  once,  by  a 
physician.  * 

TAKING  COLD 

By  "taking  cold"  we  understand  that 
through  the  influence  of  cold  upon  some  por- 
tion of  the  skin  an  impression  similar  in  na- 
ture to  that  of  shock  is  produced,  which  affects 
the  entire  body  and  manifests  itself  most  fre- 


154  Taking  Cold 

quently  in  the  form  of  a  congestion  of  the 
mucous  membrane  of  the  respiratory  tract, 
between  which  and  the  skin  there  seems  to  be 
an  intimate  connection.  Micro-organisms  play 
an  important  role  in  the  process.  They  are 
found  in  large  numbers  on  the  diseased  mucous 
surfaces.  The  changes  in  the  mucous  mem- 
brane resulting  from  the  exposure  prepare  the 
parts  for  their  growth  and  development.  The 
taking  of  cold  usually  means  previous  exposure, 
and  what  will  constitute  a  sufficient  degree  of 
exposure  in  one  individual  may  produce  no 
effect  in  another.  According  to  my  observa- 
tion, the  most  frequent  cause  of  colds  in  in- 
fancy is  the  action  of  cold  air  on  a  moist  skin. 
The  child  that  perspires  readily,  or  the  child 
that  is  made  to  perspire  by  unsuitable  cloth- 
ing, suffers  most  in  this  respect  during  the 
cold  season.  I  look  upon  inadequate  head- 
covering  as  a  most  frequent  cause  of  diseases 
of  the  respiratory  tract  in  the  young.  Most 
infants  are  dressed  for  the  daily  outing  in  a 
warm  room,  with  the  temperature  ranging 
from  75°  to  85°.  The  child  is  wrapped  in 
ample  coats,  blankets,  and  leggings;  he  is  ac- 
tive, throws  his  legs  and  arms  about ;  the  dress- 
ing thus  far  requires  quite  a  period  of  time; 


Taking  Cold  155 

he  perspires  freely,  but  the  dressing  is  not  com- 
pleted. On  the  head  is  placed  one  of  the  more 
or  loss  artistically  decorated  airy  creations 
which  are  sold  in  the  shops  as  children's  caps. 
They  furnish  little  protection  for  the  many 
square  inches  of  the  almost  bald  little  head. 
The  child  is  taken  out  of  doors ;  a  wind  is  blow- 
ing ;  the  result  is  a  cold ;  and  how  it  came  about 
is  never  understood.  He  was  supposed  to  be 
dressed  ideally  for  cold  weather.  The  idea  is 
common  and  to  a  certain  degree  proper  that  a 
child's  head  should  be  kept  cool.  This  theory, 
however,  gives  rise  to  carelessness  as  to  the 
head-dress.  During  the  colder  months  I  ad- 
vise mothers  to  make  a  skull-cap  of  thin  flannel, 
which  the  child  can  wear  under  the  regular 
outing  cap. 

Allowing  a  child  to  sit  on  the  floor  during 
the  winter  months  is  probably  the  next  most 
frequent  cause  of  taking  cold.  Kicking  off 
the  bedclothes  at  night  is  another  frequent 
cause.  Taking  the  child  from  a  warm  room 
through  a  cold  hall  is  not  without  danger. 
Holding  the  child  for  a  few  moments  by  an 
open  window  during  the  cold  weather  is  often 
followed  by  croup,  bronchitis,  and  pneumonia. 
The  uneven  temperature  of  the  living-  and 


156  Taking  Cold 

sleeping-rooms  in  many  of  our  New  York 
apartments  is  a  very  frequent  cause  of  cold. 
Frequently  during  the  day  the  temperature  will 
be  between  75°  and  80°,  but  at  night,  when  the 
fires  are  banked,  it  falls  to  55°  or  60°  or  lower. 
The  child  went  to  bed  warm  and  perspiring, 
kicked  off  the  bedclothes,  the  temperature  in 
the  room  fell,  the  body  became  chilled,  and  the 
child  took  cold. 

Among  rachitic  children  there  is  a  marked 
predisposition  to  catarrhal  affections;  they 
acquire  laryngitis  and  bronchitis  upon  very 
slight  provocation. 

In  many  instances  colds  in  infants  are  attrib- 
uted to  the  bath.  Among  dispensary  mothers 
this  is  often  considered  a  cause  of  cold.  I 
have  never  known  a  cold  to  be  due  to  a  bath. 

Colds — contagious. — Adults  and  "runabout" 
children  with  coughs  and  colds  should  not 
come  in  contact  with  infants.  There  is  un- 
doubtedly an  element  of  contagion  in  such 
cases.  It  is  a  very  bad  practice  to  have  a 
family  pocket-handkerchief.  The  youngest 
infant  is  entitled  to  a  handkerchief  indepen- 
dent of  the  other  children,  and  a  handkerchief 
should  never  do  service  for  more  than  one  in- 
dividual between  washings. 


Cough  157 

Prevention. — Mothers  can  do  little  without 
medical  aid  in  the  treatment  of  colds,  but  they 
can  do  much  in  preventing  them.  The  tem- 
perature of  the  living-room  should  range  from 
65°  to  68°  F.,  the  sleeping-room  from  50°  to 
60°  F.  Of  course  it  will  be  impossible  to 
keep  the  temperature  at  all  times  at  these  fig- 
ures, but  the  closer  it  approximates  to  them  the 
safer  the  child  will  be. 

Children  must  not  be  allowed  to  sit  on  the 
floor  during  the  winter.  They  can  have  their 
playthings  on  the  bed,  on  the  sofa,  or  in  a 
clothes-basket,  which  may  be  raised  on  two 
thick  pieces  of  wood  or  a  couple  of  books. 
There  is  always  a  draught  near  the  floor.  The 
"pen,"  referred  to  on  page  310,  is  the  best 
scheme  that  I  know  of  for  keeping  children 
from  the  floor. 

The  room  in  which  the  child  is  dressed  for 
an  outing  should  not  be  above  70°  F.  Securely 
pinning  bed-blankets  to  the  mattress,  or,  better, 
a  combination  suit  with  "feet"  will  do  much 
to  prevent  the  child  from  taking  cold  at  night. 

COUGH 

The  most  frequent  cause  of  the  temporary 
cough  seen  daily  in  children's  work  is  almost 


158  Cough 

always  an  acute  inflammatory  condition  of  the 
mucous  membrane  of  the  respiratory  tract, 
involving  usually  the  fauces,  the  larynx,  and 
bronchi,  subjects  which  are  referred  to  under 
their  respective  headings. 

Chronic  cough. — Ninety-five  per  cent,  of 
the  obscure  coughs  are  due  to  adenoid  vege- 
tations in  the  naso-pharyngeal  vault.  Incipi- 
ent tuberculous  infiltration  in  any  portion  of 
the  lungs  or  pleura  may  produce  the  persistent 
cough.  Thorough  physical  examinations  and 
careful  observation  of  the  case  for  a  few  days 
will  make  a  diagnosis  possible.  Whooping- 
cough  without  the  whoop  or  vomiting  may 
cause  a  persistent  cough.  It  runs  its  course 
and  subsides  in  from  four  to  eight  weeks.  A 
diagnosis  of  such  mild  cases  of  whooping- 
cough  is  possible  only  when  there  is  a  history 
of  exposure  to  the  disease.  I  have  had  occa- 
sion to  examine  and  treat  many  children  who 
were  brought  to  me  because  of  a  "cough" 
which  had  not  been  controlled  by  the  measures 
employed.  While  we  hear  much  of  the  cough 
of  teething,  the  "stomach  cough,"  the  "nervous 
cough,"  and  the  "habit  cough,"  it  has  never 
been  my  lot  to  see  a  case  in  which  the  cough 
was  not  connected  in  some  way  with  the  res- 


Cough  159 

piratory  tract.  Thorough  examination  of 
these  cases,  perhaps  repeated  examinations, 
will  be  required  before  the  site  of  the  trouble 
is  definitely  located,  when  it  will  almost  in- 
variably be  found  somewhere  in  the  respira- 
tory tract.  The  stomach  cough,  the  nervous 
cough,  and  the  teething  cough  formerly  stood 
for  the  persistent  cough  which  could  not  be 
accounted  for  by  physical  examination  of  the 
chest  or  by  mere  inspection  of  the  throat. 
They  are  frequently  referred  to  by  the  older 
writers.  An  elongated  uvula,  to  which  these 
obscure  coughs  have  also  been  attributed,  is 
very  rarely  a  cause.  The  history  is  usually 
only  that  of  a  persistent  cough.  It  may  be 
irritating  in  character,  keeping  the  child 
awake  at  night,  or  it  may  be  paroxysmal,  the 
attacks  being  more  severe  when  the  child  is 
lying  down.  Many  times  the  paroxysms  are 
so  severe,  being  particularly  worse  at  night, 
that  whooping-cough  is  suspected  because  of 
the  absence  of  chest  signs. 

Cough  due  to  adenoids. — An  immense 
majority  of  these  obscure  coughs  in  children 
are  due  to  adenoid  vegetations  with  or  with- 
out enlarged  tonsils.  A  child  with  such  a 
cough  may  have  the  typical  adenoid  face, 


160  Cough 

mouth-breathing,  and  other  signs  referre'd  to 
(see  Adenoids,  page  130),  or  these  symptoms 
may  be  entirely  absent.  It  is  the  latter  type 
of  case  that  is  particularly  puzzling  and  apt  to 
be  overlooked.  On  account  of  the  absence  of 
mouth-breathing  and  other  symptoms  of  nasal 
obstruction,  the  possibility  of  adenoid  vegeta- 
tions has  been  ignored.  In  these  cases 
careful  inquiry  will  usually  elicit  the 
history  of  frequent  colds,  or  what  is 
styled  ''catarrh,"  as  there  is  more  or 
less  serious  discharge  from  the  nose,  or  the 
child  is  said  to  "take  cold  in  the  head  easily." 
Digital  examination  of  the  naso-pharyngeal 
vault  will  reveal  a  fringe  of  soft  adenoid 
growth  at  the  upper  portion  of  the  posterior 
pharyngeal  wall,  not  large  enough  to  produce 
obstruction,  but  actively  secreting.  This  secre- 
tion, if  not  profuse,  is  partially  evaporated  in 
the  nostrils,  or  if  profuse,  is  discharged  from 
the  nostrils  or  passes  backward  over  the  pos- 
terior pharyngeal  wall,  thus  provoking  cough, 
when  the  child  is  up  and  about.  When  the 
child  rests  on  his  back,  the  secretion  naturally 
flows  over  the  posterior  pharyngeal  wall,  and 
a  cough  is  the  result.  Time  and  again  I  have 
relieved  the  most  obstinate  cough  by  curetting 


Cough  161 

and  removing  this  sponge-like  tissue.  In  one 
patient,  a  boy  two  years  of  age,  who  had  been 
coughing  hard  for  ten  days  with  paroxysms 
and  vomiting,  a  diagnosis  of  whooping-cough 
had  been  made  by  a  member  of  the  family  who 
had  seen  many  cases  of  whooping-cough,  and 
also  by  myself.  Adenoids  were  found  to  be 
present  in  a  slight  degree.  Their  removal 
was  advised,  with  the  idea  of  making  the 
coughing  attacks  less  severe,  when,  greatly  to 
our  surprise,  the  coughing  ceased  at  once, 
not  a  paroxysm  occurring  after  the  growth 
was  removed.  The  cough  was  due  to  the 
adenoid  vegetations  and  not  to  whooping- 
cough. 

Cough  caused  by  tracheitis. — Tracheitis  (in- 
flammation of  the  windpipe)  will  produce  a 
cough,  severe  and  intractable,  with  no  signs 
in  the  chest.  In  these  cases,  however,  the 
cough  is  usually  sudden  in  its  development.  It 
is  often  accompanied  by  slight  fever,  and  if 
the  child  is  old  enough  he  will  aid  us  by  re- 
ferring to  the  sense  of  discomfort  and  tight- 
ness which  exists  over  the  upper  portion  of 
the  chest.  Sometimes  the  sensation  will  be 
described  as  a  burning,  which  is  located  directly 

over  the  trachea. 
11 


1 62  Tonsillitis 

TONSILLITIS 

Tonsillitis,  or  inflammation  of  the  tonsils, 
is  a  very  common  ailment  among  children 
during  the  cooler  months.  It  usually  follows 
exposure.  The  onset  is  generally  sudden,  with 


FIG.   9.      COLD    COMPRESS 

high  fever — 103°  to  105°  F., — pain,  swelling, 
headache,  and  general  muscular  soreness.  In- 
spection of  the  throat  will  show  the  tonsils  to 
be  swollen  and  inflamed.  The  entire  throat 
generally  has  a  congested  appearance.  No 
other  changes  may  be  noticed.  In  the  majority 
of  cases,  however,  the  tonsils  will  be  found 


Cold  in  the  Head          163 

studded  with  small  white  dots  of  a  cheesy  ma- 
terial. If  the  case  is  seen  two  or  three  days 
after  the  beginning  of  the  illness  the  dots  may 
have  coalesced,  forming  large  yellowish  patches 
which  so  closely  resemble  the  appearance  of 
the  throat  in  diphtheria,  that  it  may  be  im- 
possible for  the  physician  without  the  aid  of 
a  microscope  to  differentiate  between  the  two 
diseases.  An  attack  of  tonsillitis  runs  its 
course  in  from  two  to  five  days. 

Matiagement. — Cold  applications,  cold  com- 
presses (see  cut)  to  the  throat,  and  cold  spong- 
ings  of  the  body  afford  the  patient  much  re- 
lief. A  dose  of  castor-oil  given  at  the  first 
symptom  of  the  disorder  will  always  be  of 
value. 

COLD  IN  THE  HEAD  (CORYZA) 

A  cold  in  the  head  is  a  very  frequent  occur- 
rence in  the  young,  and  while  not  serious  if 
the  trouble  limits  itself  to  the  mucous  mem- 
brane of  the  nose,  it  is,  nevertheless,  a  source 
of  much  annoyance  to  both  mother  and  child. 
The  mucous  membrane  of  the  nasal  passages 
is  congested  and  swollen.  The  nostrils  of  in- 
fants in  health  are  very  narrow,  so  that  a  slight 


164  Bronchitis 

congestion  will  greatly  interfere  with  the 
breathing. 

The  first  sign  to  be  noticed  is  that  when 
the  child  is  nursing  he  is  unable  to  breathe 
easily  through  the  nose,  and  frequent  rests  are 
necessary.  Sleep,  for  this  reason,  is  also  inter- 
fered with.  The  baby  sneezes  more  than  usual 
and  there  is  a  watery  discharge  from  the  nose 
with  usually  a  degree  or  two  of  fever. 

Management. — With  the  onset  of  the  first 
symptoms,  one  teaspoonful  of  castor-oil  will 
be  of  service.  A  few  drops  of  melted  vaseline 
or  liquid  albolene  may  be  dropped  into  the  nos- 
trils every  two  hours. 

The  danger  from  a  so-called  "cold  in  the 
head"  rests  in  the  fact  that  the  inflammation 
does  not  always  limit  itself  to  these  parts.  It 
is  very  liable  to  extend  to  other  portions  of  the 
respiratory  tract,  terminating  sometimes,  even 
if  properly  treated,  in  bronchitis  of  broncho- 
pneumonia. 

BRONCHITIS 

Bronchitis  may  occur  as  a  primary  illness, 
or  it  may  follow  a  cold  in  the  head,  laryn- 
gitis, or  any  inflammatory  condition  of  the 


Bronchitis  165 

respiratory  tract.  It  often  occurs  as  a  com- 
plication of  other  diseases.  There  is  almost 
always  more  or  less  bronchitis  with  measles. 
In  bronchitis  we  have  a  serious  illness  not 
necessarily  serious  in  itself  but  mainly  so  be- 
cause of  the  frequency  with  which  it  leads 
to  catarrhal  pneumonia.  Bronchitis  in  a  deli- 
cate child  requires  but  a  little  bad  manage- 
ment or  neglect  and  pneumonia  will  surely 
develop. 

The  reason  why  bronchitis  is  a  dangerous 
illness  in  a  young  child  is  because  of  the  lack 
of  development  of  the  parts  which  form  the 
chest  walls.  The  ribs  are  soft  and  the  mus- 
cles weak.  The  bronchial  tubes  collapse 
readily.  In  an  older  child  the  bronchial  secre- 
tions are  coughed  into  the  mouth  and  swal- 
lowed or  expectorated.  The  young  infant 
cannot  expectorate.  When  the  secretion  is 
viscid  and  thick,  the  weak  chest-wall  fails  to 
furnish  the  power  required  to  expel  it  and 
instead  it  is  drawn  deeper  into  the  lungs,  the 
smaller  tubes  become  clogged  with  mucus,  the 
air  vesicles  collapse,  bacteria  multiply  rapidly 
in  the  confined  secretions,  and  pneumonia  re- 
sults. 

Bronchitis    is    indicated    by    coughing    and 


166  Bronchitis 

wheezing,  and  what  the  mother  often  calls 
"a  drawing  of  the  chest."  In  many  cases 
fever  is  present  in  a  marked  degree.  The 
severity  of  the  cough  and  the  other  symptoms 
depend  entirely  upon  the  severity  of  the  lesions. 
In  many  cases,  if  seen  early  the  disease  will 
respond  to  treatment  in  a  day  or  two. 

Management.  —  A  generous  counter-irrita- 
tion of  the  chest  with  one  part  of  turpentine 
and  three  parts  of  camphorated  oil  is  a  useful 
measure,  the  applications  to  be  made  twice  a 
day — morning  and  evening.  What  is  better, 
however,  is  the  use  of  the  mustard  plaster, 
made  by  mixing  one  part  of  mustard  with 
three  parts  of  flour,  sufficient  warm  water 
being  added  to  make  a  paste,  which  may  be 
spread  on  cheese-cloth  or  thin  muslin.  It 
should  be  large  enough  to  encircle  the  chest, 
fitting  the  child  like  a  jersey.  This  is  covered 
with  another  piece  of  similar  material  and  the 
plaster  is  complete.  It  should  be  wrapped 
around  the  chest  and  allowed  to  remain  from 
ten  to  fifteen  minutes — until  the  skin  is  thor- 
oughly reddened. 

Proprietary  cough  mixtures  and  home  reme- 
dies should  never  be  relied  upon  for  the  treat- 
ment of  bronchitis  in  children. 


Croup  167 

CROUP 

CATARRHAL  CROUP;    DIPHTHERITIC  CROUP 

There  are  two  varieties  of  croup,  catarrhal 
and  diphtheritic:  catarrhal  croup  is  a  catarrhal 
inflammation  of  the  larynx,  and  diphtheritic 
croup  a  membranous  inflammation  of  the 
larynx. 

Catarrhal  croup  may  begin  in  two  ways. 
The  child  will  suffer  from  snuffles,  indicating 
a  simple  cold  in  the  head,  which  is  followed 
by  a  slight  fever  and  a  mild  cough.  The  cough 
rapidly  becomes  worse  and  is  hoarse  and  bark- 
ing in  character,  becoming  more  severe  toward 
evening.  As  a  rule,  the  fever  is  not  high.  In 
the  evening  of  the  second  or  third  day  of  the 
illness,  sometimes  the  first  day,  signs  of  ob- 
struction to  the  breathing  become  apparent. 
The  inspiration  is  labored  and  accompanied 
by  a  croaking  sound.  The  child  cannot  speak 
above  a  whisper. 

Probably  not  over  half  of  the  cases  show 
this  gradual  development.  In  many  the  on- 
set is  sudden:  the  child  goes  to  bed  as  well  as 
usual;  after  a  quiet  sleep  of  a  few  hours  he 
awakes  suddenly,  sits  up  in  bed,  and  with 


i68  Croup 

high-pitched  cough,  straining  for  breath,  he 
startles  the  household. 

Membranous  or  diphtheritic  croup  is  much 
the  more  dangerous  affection,  but  to  the 
mother  there  is  no  means  of  distinguishing 
between  the  two  forms,  unless  the  child  has 
diphtheria  and  the  croup  follows.  The  two 
forms  may  appear  in  identically  the  same  way, 
although  the  onset  of  the  diphtheritic  croup 
is  usually  more  gradual. 

Management. — In  case  of  a  severe  cough  or 
a  sharp  attack  of  croup  in  one  of  the  children, 
the  mother  or  nurse  in  charge  has  three  duties 
to  perform :  send  for  a  doctor,  isolate  the  child, 
and  give  him  a  teaspoonful  of  the  syrup  of 
ipecac,  which  may  be  repeated  in  fifteen  min- 
utes if  there  is  no  vomiting.  Every  case  of 
croup  should  be  quarantined  until  the  nature 
of  the  trouble  is  determined  If  it  is  catarrhal, 
no  harm  will  be  done  by  the  isolation.  If  it 
is  diphtheritic,  the  lives  of  other  members  of 
the  household  may  be  saved  by  the  precaution. 
If  a  croup-kettle  is  at  hand  (see  cut  10),  it 
should  be  brought  into  use  after  making  a  tent 
by  covering  or  draping  the  crib  with  a  sheet 
(see  cut  n).  If  an  alcohol  lamp  is  used  for 
the  kettle  it  is  far  safer  to  place  the  croup- 


Croup 


169 


kettle  in  a  large  dish  pan.     A  common  teapot 
can  be  used  in  an  emergency.     One  teaspoon- 


FIG.    10.         THE    HOLT    CROUP-KETTLE 

ful  of  tincture  of  benzoin  or  pine-needle  oil 
is  added  to  one  quart  of  water  and  placed  in 
the  kettle,  which  is  heated  by  the  alcohol  lamp 
attachment.  A  cold  compress  (page  162)  ap- 
plied to  the  throat  is  often  beneficial  also.  It 


170 


Croup 


should  be  thoroughly  wrung  out,  covered  with 
some  dry  material,  and  changed  every  twenty 


FIG.    II.      CRIB    PREPARED    FOR    STEAM    INHALATION 

minutes.     The  child  should  receive  a  laxative 
as  early  as  possible  in  the  attack. 


Pneumonia  17 * 

PNEUMONIA 

Pneumonia,  sometimes  referred  to  as  in- 
flammation of  the  lungs,  or  lung  fever,  occurs 
very  frequently  in  infants  and  young  children. 
It  may  appear  as  an  independent  affection  or 
as  a  complication  of  other  diseases.  There  are 
two  varieties  which  are  commonly  met  with  in 
the  young:  lobar  pneumonia,  which  corre- 
sponds closely  to  the  adult  type,  and  broncho- 
pneumonia,  or,  as  it  is  sometimes  called,  co 
tarrhal  pneumonia. 

Lobar  pneumonia  usually  results  from  ex- 
posure— a  sudden  chill  of  some  part  of  the  sur- 
face of  the  body. 

Broncho-pneumonia  is  usually  the  outcome 
of  bronchitis  or  what  is  known  as  "common 
cold." 

The  latter  is  most  frequently  seen  in  chil- 
dren and  is  usually  the  variety  which  occurs 
as  a  complication  of  other  diseases.  The  mode 
of  onset  of  the  two  types  varies. 

Lobar  pneumonia. — With  lobar  pneumonia 
the  onset  is  sudden;  there  may  be  a  chill  or  a 
convulsion.  Sometimes  vomiting  ushers  in 
an  attack.  The  fever  rises  rapidly  to  103°  or 
105°  F.  The  face  is  flushed  and  wears  an 


i72  Pneumonia 

anxious  expression;  the  breathing  is  rapid,  the 
respirations  being  from  40  to  60  a  minute, 
the  expiration  being  accompanied  by  a  peculiar, 
partially  suppressed  sigh.  The  child  is  very 
restless,  often  delirious,  or  there  may  be  stupor, 
with  symptoms  pointing  to  a  complicating 
meningitis.  All  the  symptoms  disappear  with 
the  advent  of  the  crisis,  when  the  fever  sud- 
denly abates  and  fails  to  rise  again.  The  crisis 
may  be  expected  any  time  between  the  third 
and  eleventh  day  of  the  recovery  cases.  In  the 
majority  of  my  cases  it  has  occurred  from  the 
fifth  to  the  seventh  day,  in  a  few  not  until 
the  ninth  day,  and  in  two  it  did  not  occur 
until  the  eleventh  day,  and  in  one  on  the  four- 
teenth day. 

The  prognosis  of  lobar  pneumonia  in  chil- 
dren is  good.  A  very  small  percentage  fail  to 
recover.  A  patient  of  mine,  a  three-year-old 
boy,  passed  through  two  distinct  attacks  in  a 
single  winter,  the  second  after  an  interval  of 
ten  weeks. 

Broncho-pneumonia. — In  catarrhal  or  bron- 
cho-pneumonia the  story  is  different.  There 
may  be  a  pneumonia  at  the  commencement  of 
the  illness,  but  according  to  my  observation, 
which  covers  several  hundred  cases,  the  ma- 


Pneumonia  173 

jority  begin  with  sypmtoms  of  a  common  cold 
or  bronchitis,  the  lungs  becoming  involved 
gradually.  In  other  words,  the  onset  is  grad- 
ual, not  sudden,  whether  it  occurs  indepen- 
dently or  as  a  complication  of  some  other 
disease.  There  is  cough,  often  distressing, 
moderate  fever,  rapid  breathing,  loss  of  appe- 
tite, and  later,  emaciation.  Broncho-pneu- 
monia in  children  is  an  affection  of  extreme 
gravity.  There  is  no  well-defined  crisis  as  in 
lobar  pneumonia.  The  disease  may  last  a  week 
or  two  weeks,  or  it  may  continue  for  months. 
In  one  of  my  cases — a  child  eighteen  months 
of  age, — the  disease  continued  three  months 
before  the  low  fever  abated  and  the  lungs  were 
clear.  The  recovery  cases  often  require  from 
three  to  four  weeks  before  the  lungs  may  be 
considered  normal. 

Care  and  prevention. — The  sick-room  of  a 
patient  ill  with  pneumonia  should  be  large, 
with  one  window  open  at  least  four  inches 
from  the  top  on  the  coldest  days.  The  tem- 
perature of  the  room  should  not  be  below  55° 
F.  or  above  65°  F.  The  child  should  be  put 
on  a  reduced  diet  of  animal  broths,  thin  gruels, 
and  diluted  milk. 

Prevention  resolves  itself  into  proper  care 


i?4    The  Contagious  Diseases 

of  the  child,  proper  clothing,  avoidance  of 
unnecessary  exposure,  and  an  appreciation  of 
the  fact  that  with  a  child  it  is  almost  as  neces- 
sary to  call  a  physician  for  a  common  cold  or 
bronchitis  as  it  is  for  scarlet  fever  or  diph- 
theria. 

THE  CONTAGIOUS  DISEASES 

A  contagious  disease  is  one  due  to  a  specific 
poison  which  under  favoring  conditions  pos- 
sesses the  power  of  reproducing  itself  in  the 
person  of  another.  The  poison  of  the  disease, 
the  contagium,  may  be  transmitted  either  di- 
rectly by  contact  with  an  individual  suffering 
from  the  disease,  or  indirectly  by  means  of 
some  person  or  object,  such  as  the  clothing 
or  hands  of  the  attendants,  which  have  been 
in  contact  with  the  one  infected.  According 
to  my  observation,  personal  contact  with  the 
infected  is  required  in  a  large  proportion  of 
cases.  Measles  and  whooping-cough  are  un- 
questionably the  most  contagious  diseases  of 
this  type,  requiring  for  their  transmission  only 
a  very  slight  exposure.  German  measles  and 
chicken-pox  are  next  in  order  of  communica- 
bility,  while  scarlet  fever  is  less  contagious 
than  any  of  those  mentioned — a  close  contact 


Scarlet  Fever  175 

and  a  fairly  long  exposure  being  usually  re- 
quired. Clothing  may  be  infected  by  the  con- 
tagium  of  scarlet  fever  and  diphtheria,  the 
poison  remaining  inactive  for  a  long  time. 

Incubation  period. — By  this  we  understand 
the  time  usually  required  for  the  disease  to 
develop  after  exposure. 

Diphtheria variable. 

Scarlet  fever five  to  seven  days. 

Measles nine  to  twelve  days. 

Whooping-cough . . .  seven  to  fourteen  days. 

Chicken-pox fourteen  to  twenty-one  days. 

Mumps ten  to  twenty  days. 

German  measles ....  two  to  three  weeks. 

Diphtheria  through  personal  contact  alone 
is  probably  the  least  contagious  of  any  of  the 
diseases  belonging  in  this  group.  Its  virulence, 
however,  renders  every  preventive  measure 
imperative. 

Smallpox,  thanks  to  compulsory  vaccination, 
is  seen  so  rarely  that  it  need  not  be  considered 
here. 

SCARLET  FEVER 

Scarlet  fever  is  one  of  the  most  important 
of  the  contagious  diseases,  and  whether  a  case 
is  mild  or  severe  it  requires  the  greatest  watch- 


176  Scarlet  Fever 

fulness  on  the  part  of  both  physician  and  nurse, 
nor  can  their  vigilance  be  safely  relaxed  until 
the  patient  has  been  apparently  well  for  at  least 
five  or  six  weeks. 

Incubation. — The  period  of  incubation 
varies  considerably.  In  the  majority  of  cases 
the  first  sign  of  trouble  is  noticed  from  three 
to  five  days  after  exposure.  In  one  of  my 
cases  twelve  days  elapsed  between  the  time  of 
exposure  and  the  initial  symptom.  If,  how- 
ever, nine  days  pass  without  evidence  of  ill- 
ness, the  child  may  ordinarily  be  considered 
safe,  but  the  exposed  should  not  come  in  con- 
tact with  other  children  until  at  least  four- 
teen days  have  elapsed.  Infection  usually 
takes  place  from  direct  contact,  although  the 
contagium,  the  nature  of  which  is  unknown, 
may  be  carried  by  means  of  clothing,  toys, 
books,  or  a  third  person.  Doctors  who  do  not 
wear  gowns  while  attending  scarlet  fever  pa- 
tients, and  are  careless  about  washing  their 
hands  after  examining  such  cases,  may  them- 
selves carry  the  disease.  One  attack  usually 
protects  against  a  second,  although  cases  are  .on 
record  of  the  occurrence  of  two  or  three  at- 
tacks in  the  same  individual. 

The  onset. — The  onset  of  scarlet  fever  is 


Scarlet  Fever  177 

sudden,  often  with  vomiting,  occasionally  with 
a  convulsion,  always  with  fever  and  sore 
throat.  The  fever  is  usually  high,  103°  to 
105°  F.,  though  it  may  be  low, — 101°  to  102° 
F.  When  the  latter  is  the  case  the  course  of 
the  disease  will  probably  be  mild.  Whether 
the  fever  is  high  or  low,  the  deeply  red,  con- 
gested throat  is  usually  present. 

The  rash. — From  twenty-four  to  thirty-six 
hours  after  the  initial  symptom  the  rash  makes 
its  appearance.  In  many  mild  cases  it  will  be 
the  first  symptom  noticed.  The  character  of 
the  rash,  its  intensity,  and  the  height  of  the 
fever  indicate  fairly  well  the  severity  of  the 
attack.  The  chest  and  abdomen  are  usually 
the  site  of  the  first  appearance  of  the  rash.  It 
is  composed  of  minute  red  dots  so  closely  set 
together  as  to  give  the  skin  a  deep  scarlet  color. 
The  extent  of  the  rash  varies  greatly;  in  some 
cases  it  covers  the  entire  body  and  lasts  from 
six  to  seven  days.  In  others,  it  is  much  less 
distinct,  covering  only  limited  areas,  and  may 
last  for  only  a  few  hours.  In  one  of  my  cases 
it  was  visible  for  only  six  hours  after  it  was 
first  noticed;  while  in  all  other  respects  the 
case  was  one  of  typical  scarlet  fever. 

Desquamation. — Ordinarily  the  rash  begins 


178          German  Measles 

to  fade  about  the  fourth  or  fifth  day  and  is 
followed  by  the  desquamation  period.  This 
is  also  variable  in  extent;  there  may  be  but 
a  light  peeling  of  the  palms  of  the  hands,  and 
of  the  finger-tips  about  the  nails,  or  it  may 
be  most  profuse,  the  epidermis  peeling  off  in 
large  flakes  from  the  entire  surface  of  the 
body.  From  two  to  three  weeks  are  required 
to  complete  this  process. 

Complications. — Complications  are  a  com- 
mon occurrence  in  scarlet  fever,  and  it  is  the 
complications  which  are  usually  the  cause  of 
death  in  the  fatal  cases.  The  kidneys,  heart, 
lungs,  and  ears  are  particularly  liable  to  seri- 
ous involvement. 

An  error  frequently  made  is  to  allow  the 
child  convalescent  from  scarlet  fever  to  be  out 
of  bed  too  early.  He  should  never  be  allowed 
to  run  about  before  four,  or,  better  still,  five  or 
six  weeks  have  elapsed.  The  peeling  may  be 
hastened,  the  disease  curtailed,  and  the  danger 
of  spreading  lessened  by  a  daily  sponge  bath  fol- 
lowed by  an  inunction  with  sweet  oil  or  vaseline. 

GERMAN  MEASLES 

German  measles  is  a  contagious  disease  of 
a  very  mild  type,  ordinarily  the  rash  being 


Mumps  179 

the  symptom  of  illness.  This  may  have  been 
preceded,  however,  by  a  slight  chilliness  and 
soreness  of  the  muscles.  The  eruption  is  of 
a  reddish-brown  color  and  appears  more  ex- 
tensively on  the  face  and  chest  than  on  other 
parts  of  the  body.  The  spots  vary  in  size  from 
a  pin-head  to  a  flaxseed.  In  well-developed 
cases  the  rash  may  cover  the  entire  surface  of 
the  body.  The  temperature  is  usually  low  and 
lasts  but  a  day  or  two.  I  have  never  seen  it 
above  102°  F.  There  is  little  or  no  inflamma- 
tion of  the  eyes,  nose,  or  throat,  in  marked  con- 
tradistinction to  measles.  There  is  no  cough 
and  the  child  suffers  very  little  inconvenience. 
The  glands  behind  the  ear  and  at  the  sides  of 
the  neck  are  almost  always  enlarged  and  sensi- 
tive,— this  with  the  fever  and  the  rash  com- 
prising the  chief  symptoms  of  the  disease. 
The  duration  of  the  rash  varies  from  one  to 
three  days.  Usually  at  the  end  of  forty-eight 
hours  the  skin  will  be  found  clear. 

My  treatment  is :  two  or  three  days  in  bed 
and  a  light  diet. 

MUMPS 

Mumps  is  an  inflammation  of  one  or  both 
parotid  glands.     One  attack  usually  protects 


i8o  Mumps 

against  another.  The  disease  is  usually  ac- 
quired by  contact  with  the  infected.  It  is  ex- 
tremely doubtful  that  it  can  be  carried  by  a 
third  party.  The  period  of  time  required  for 
the  development  of  the  disease  after  exposure 
varies  considerably;  but  from  ten  to  twenty 
days  may  be  considered  the  period  of  incuba- 
tion. 

The  first  symptoms  are  .similar  to  those 
of  the  other  contagious  diseases.  There  is 
loss  of  appetite,  headache,  languor,  and  slight 
fever.  In  addition  to  these  general  symptoms, 
the  child  complains  of  pain  upon  swallowing, 
or  upon  moving  the  jaw.  Vinegar  or  any  acid 
substance  taken  into  the  mouth  causes  con- 
siderable pain  or  discomfort  behind  the  jaws 
and  under  the  ears.  In  a  few  hours  there  will 
be  noticed  a  swelling  of  the  parotid  gland  in 
front  of  and  under  the  ear.  Both  sides  rarely 
begin  to  swell  at  the  same  time;  the  swelling  of 
one  gland  usually  precedes  that  of  the  other  by 
a  couple  of  days.  It  increases  gradually  for 
two  or  three  days  until  it  reaches  its  height, 
when  it  begins  to  subside  slowly,  reaching  the 
normal  in  eight  or  ten  days  from  its  beginning. 
The  temperature  during  the  attack  ranges  from 
100°  to  103°  F. 


Mumps  181 

The  complications  of  mumps  in  children  are 
few,  and  the  disease  cannot  be  regarded  as 
dangerous.  Acute  Bright's  disease  followed 
an  attack  of  mumps  in  one  of  my  patients. 
Swelling  of  the  testicles  is  a  comparatively 
rare  occurrence.  Ear  disease  is  an  infrequent 
but  possible  complication.  Multiple  abscesses 
may  develop  in  the  parotid  gland,  but  this  is 
also  a  very  rare  occurrence.  Other  acute 
glandular  swellings  at  the  angle  of  the  jaw 
are  often  mistaken  for  mumps;  in  mumps, 
however,  the  swelling  is  always  in  front  of, 
under,  and  behind  the  ear.  A  simple  glandu- 
lar enlargement  may  be  located  at  any  point 
under  or  behind  the  jaw. 

Management. — A  child  with  mumps  should 
be  kept  in  bed  until  the  swelling  has  subsided, 
and  given  plain,  easily  digested  food.  The 
mouth  should  be  rinsed  after  each  meal  with 
a  saturated  solution  of  boracic  acid.  For  the 
pain  and  discomfort  caused  by  the  swelling, 
hot  applications  answer  best.  Flannel  wrung 
out  of  very  hot  water  and  bound  upon  the  parts 
always  furnishes  some  relief.  The  flannel 
should  be  kept  hot  by  repeatedly  dipping  it  into 
hot  water.  The  heat  will  be  retained  better  if 
the  flannel  is  covered  with  oiled-silk. 


1 82          Whooping-Cough 
WHOOPING-COUGH 

In  whooping-cough  we  have  one  of  the  most 
dangerous  diseases  of  childhood,  dangerous  in 
the  extreme  for  the  very  young,  the  delicate, 
and  the  rachitic.  In  itself  it  is  seldom  directly 
fatal,  but  the  frequent  complications  of 
catarrhal  pneumonia  in  winter  and  intestinal 
diseases  in  summer  make  it  indirectly  responsi- 
ble for  the  loss  of  many  lives. 

The  period  of  incubation  ranges  from  seven 
to  fourteen  days.  At  the  commencement  of 
the  disease  the  cough  is  not  severe  and  often 
cannot  be  distinguished  from  that  of  bronchitis 
or  a  common  cold.  The  cough,  however,  does 
not  respond  to  treatment  for  coughs  and  colds ; 
it  increases  in  severity,  becoming  paroxysmal 
in  character  and  worse  at  night.  During  the 
paroxysms  the  eyes  water,  the  face  becomes 
red  and  congested,  the  seizure  often  ending  in 
vomiting.  The  characteristic  whoop  usually 
develops  after  ten  days  or  two  weeks.  In  the 
mild  cases  there  may  be  but  two  or  three 
paroxysms  daily;  in  the  severe  cases  there  are 
usually  from  twenty  to  thirty  in  twenty- four 
hours.  I  have  seen  a  few  cases  in  which  the 
disease  was  so  mild  that  the  whoop  never  ap- 


Whooping-Cough          183 

peared,  while  others  whooped  but  once  during 
an  entire  attack.  The  disease  varies  not  only 
in  its  severity,  but  in  its  duration  as  well.  Oc- 
casionally cases  are  seen  which  run  the  entire 
course  in  four  weeks;  unfortunately,  they  are 
rare.  As  a  rule,  from  eight  to  ten  weeks  elapse 
before  the  child  may  be  considered  well. 

As  long  as  the  child  continues  to  whoop,  or 
the  cough  is  distinctly  paroxysmal,  it  is  not 
safe  for  him  to  come  in  contact  with  the  un- 
protected. The  active  stage,  during  which  the 
paroxysms  are  frequent  and  severe,  rarely  lasts 
longer  than  two  or  three  weeks. 

Recurrence  of  the  whoop. — Sometimes  after 
a  period  of  three  or  four  months  without 
whooping,  the  child  takes  cold,  develops  a 
cough  paroxysmal  in  character,  and  the  whoop 
returns;  but  this  does  not  mean  that  there  is  a 
return  of  the  whooping-cough,  and  such  chil- 
dren need  not  be  quarantined. 

Maiwgement. — Whooping-cough  cannot  be 
cured;  it  must  run  its  course.  Much  may  be 
done,  however,  to  relieve  it,  by  the  use  of  the 
pertussis  vaccines.  This  treatment  can  only 
be  applied  by  a  physician  who  should  be  con- 
sulted early  in  the  attack  or  if  the  child  has 
been  exposed.  Other  than  this  the  home  treat- 


1 84  Diphtheria 

ment  demands  an  abundance  of  fresh  air.  The 
child  should  spend  the  greater  part  of  every 
pleasant  day  out  of  doors  and  sleep  with  the 
window  open  an  inch  or  two  from  the  top,  re- 
gardless of  the  weather. 

There  are  certain  drugs  which  appreciably 
relieve  the  paroxysm,  but  they  must  always  be 
ordered  by  a  physician. 

DIPHTHERIA 

Diphtheria  is  a  disease  due  to  a  germ  which 
is  known  as  the  Klebs-Loeffler  bacillus.  The 
mucous  membrane  of  the  throat  or  nose  are 
the  parts  primarily  attacked.  The  disease  is 
usually  of  slow  and  insidious  onset,  requiring 
two  or  three  days  for  its  complete  development. 
The  period  of  incubation  varies  greatly:  a 
child  may  develop  diphtheria  within  twenty- 
four  hours  after  exposure,  or  it  may  be  delayed 
a  month  or  six  weeks.  In  children  who  have 
been  exposed,  there  should  be  a  microscopical 
examination  of  the  secretion  from  the  throat, 
which  may  settle  the  question  as  to  the  child's 
liability  to  contract  the  disease. 

The  first  symptoms  are  fever  and  restless- 
ness, loss  of  appetite,  and  disinclination  to  play. 


Diphtheria  185 

The  child  may  complain  of  pain  upon  swallow- 
ing, and  in  many  cases,  very  early  in  the  at- 
tack, swelling  many  be  noticed  at  the  angle  of 
the  jaw.  Inspection  of  the  throat  shows  the 
characteristic  patches  of  the  membrane.  In 
some  cases  these  patches  resemble  a  thin  layer 
of  putty  spread  over  the  parts.  Others  present 
the  appearance  of  a  very  light-yellow  paint 
splashed  upon  the  tonsils  and  adjacent  parts. 
The  membrane  may  be  located  in  the  nose, 
throat,  larynx,  eye, — in  fact,  any  mucous  sur- 
face may  become  infected;  fresh  wounds  may 
also  become  infected.  The  usual  sites,  how- 
ever, are  the  nose,  throat,  and  larynx. 

Transmission. — The  disease  may  be  trans- 
mitted by  direct  contact,  by  means  of  contami- 
nated clothing,  toys,  pictures,  books,  or  the 
germs  may  be  carried  on  the  hands  or  clothing 
of  an  attendant. 

Recurrence. — One  attack  does  not  protect 
against  another.  There  is  evidence  that  a  cer- 
tain degree  of  immunity  is  established,  but  it 
probably  is  not  effective  for  more  than  a  few 
months.  Diphtheria  does  not  run  a  definite 
course,  like  the  other  infectious  diseases.  We 
cannot  say  that  certain  definite  signs  will  be 
present  on  certain  days.  It  is  the  most  uncer- 


1 86  Diphtheria 

tain  and  treacherous  disease  with  which  we 
have  to  deal. 

Management. — The  only  treatment  of  value 
other  than  supportive  measures  is  the  use  of 
antitoxin,  which  must  be  given  early  in  the 
disease — as  soon  as  a  diagnosis  of  diphtheria 
is  made.  In  fact,  I  believe  it  is  advisable  to 
give  it  in  all  cases  where  there  is  any  uncer- 
tainty as  to  whether  the  case  is  tonsillitis  or 
diphtheria.  Much  valuable  time  may  be  lost 
by  delay.  The  dosage  and  frequency  of  ad- 
ministration of  antitoxin  must  be  determined 
according  to  the  nature  of  the  case  by  the  at- 
tending physician.  During  convalescence,  the 
child  must  not  be  allowed  to  mingle  with  other 
children  until  a  bacteriological  examination  of 
the  throat  shows  it  to  be  free  from  diphtheritic 
germs. 

The  instructions  for  the  preparation  of  the 
sick-room,  for  disinfection  and  quarantine,  will 
be  found  on  pages  191-194. 


CHICKEN-POX 

Chicken-pox  is  one  of  the  milder  contagious 
diseases.  Among  several  hundred  cases  I  have 
seen  but  two  that  were  severe  enough  to  endan- 
ger life. 

The  period  of  incubation  is  quite  long, — 
from  fourteen  to  twenty-one  days.  There  is 
slight  fever  at  the  onset,  rarely  high  enough, 
however,  to  be  noticed  by  the  mother  or  nurse. 
More  frequently  the  first  sign  of  the  disease 
is  the  characteristic  eruption,  which  may  ap- 
pear on  any  portion  of  the  body,  the  scalp 
sometimes  being  particularly  involved.  The 
rash  consists  of  very  small  blisters  which  from 
a  distance  give  to  the  skin  the  appearance  of 
having  been  sprinkled  with  water.  The  fluid 
soon  disappears,  leaving  a  dark-colored  crust. 
When  the  crusts  fall,  a  small  scar  is  often  left, 
which  may  remain  for  several  months.  In  an 
ordinary  case  the  skin  will  not  be  clear  before 
the  end  of  the  third  or  fourth  week. 

Management. — The  child  should  be  kept  in- 
doors during  the  attack,  and  given  a  reduced 
187 


1 88  Measles 

diet.  The  itching  is  often  relieved  by  sponging 
with  a  weak  solution  of  alcohol  in  water, — 
four  ounces  to  a  pint, — followed  by  a  gentle 
application  of  vaseline. 

I  never  advise  quarantine  against  chicken- 
pox  except  to  avoid  needless  exposure  of  very 
young  or  delicate  children  in  the  family.  The 
patient  should  not  return  to  school  or  be  al- 
lowed to  mingle  with  other  children — in  short, 
is  not  to  be  considered  well — until  the  skin  is 
clear. 

MEASLES 

The  incubation  period  of  measles — the  time 
required  between  the  exposure  and  the  develop- 
ment of  the  first  symptom — varies  between  nine 
and  twelve  days.  One  attack  usually  protects 
against  a  second.  This,  however,  is  not  invari- 
ably the  case. 

The  onset  of  the  disease  closely  resembles 
that  of  a  common  cold.  The  symptoms  are 
slight  fever,  100°  to  102°  F.,  redness  of  the 
eyes  and  intolerance  of  light,  a  watery  dis- 
charge from  the  nose,  a  dry,  hard  cough,  pain 
on  swallowing,  and  loss  of  appetite.  The  pecul- 
iar swollen,  congested  condition  of  the  eyes 


Measles  189 

and  face  often  makes  a  diagnosis  possible  be- 
fore the  appearance  of  the  rash. 

Rash. — This  usually  first  appears,  from  the 
second  to  the  fourth  day  of  the  illness,  upon  the 
face  and  chest.  At  first  there  are  small,  irregu- 
larly shaped  spots  said  to  resemble  fleabites. 
The  spots  coalesce,  the  rash  extends,  and  in 
one  or  two  days  the  greater  portion  of  the  skin 
is  involved.  The  rash  remains  at  its  height 
for  two  or  three  days,  when  it  begins  to  fade, 
and  in  two  or  three  days  more  the  skin  becomes 
clear.  With  the  subsidence  of  the  rash, 
desquamation  or  peeling  of  the  skin  begins. 
This  consists  in  the  shedding  of  fine,  thin 
scales.  The  fever  and  prostration  keep  pace 
fairly  well  with  the  rash. 

Fever. — The  fever,  which  may  range  be- 
tween 102°  and  105°  F.,  reaches  its  highest 
point  with  the  complete  development  of  the 
rash.  With  the  fading  of  the  rash  the  fever 
also  moderates. 

Cough  and  bronchitis. — The  cough  in  mea- 
sles is  hard  and  dry  in  character  and  is  often 
quite  severe.  It  must  be  remembered  that  the 
congestion  of  the  respiratory  mucous  mem- 
brane which  causes  the  cough  is  a  part  of  the 
disease.  The  cough  may  be  relieved,  but  it 


i9°  Measles 

will  not  subside  until  the  disease  has  run  its 
course.  In  many  families  but  little  attention  is 
paid  to  measles — it  is  regarded  with  more  or 
less  indifference.  While,  in  most  instances, 
the  disease  may  not  be  particularly  dangerous, 
we  must  remember  that  it  is  sometimes  quite 
virulent,  and  domestic  treatment  should  never 
be  relied  upon.  There  is  always  more  or  less 
bronchitis,  which  in  young  and  delicate  infants 
constitutes  a  severe  complication,  leading,  as 
it  often  does,  to  catarrhal  pneumonia. 

The  eyes. — There  is  always  considerable  in- 
volvement of  the  eyes,  the  lids  being  red  and 
swollen,  with  a  free  secretion  of  watery  mucus. 

Management. — The  eyes  should  be  washed 
three  or  four  times  daily  with  a  saturated  solu- 
tion of  boracic  acid,  a  tablespoonful  to  one  pint 
of  boiling  water.  Their  sensitive  condition 
requires  also  a  darkened  room,  and  failure  to 
appreciate  this  fact  has  often  resulted  in  their 
permanent  injury.  A  darkened  room,  how- 
ever, does  not  mean  a  room  devoid  of  ventila- 
tion; fresh  air  for  a  patient  with  a  contagious 
disease  is  almost  as  important  as  nourishment. 
The  diet  must  be  simple ;  only  fluid  diet  should 
be  given  to  "runabouts,"  while  for  infants  the 
usual  milk  mixture  should  be  diluted  with 


The  Sick-Room  191 

boiled  water  from  one-third  to  one-half.  A 
sponge  bath  two  or  three  times  daily  using  one 
tablespoonful  Bicarbonate  Soda  in  half  a  gal- 
lon of  water  followed  by  an  inunction  with 
vaseline  will  furnish  great  relief  from  the  itch- 
ing and  renders  the  patient  generally  much 
more  comfortable. 

Children  convalescent  from  measles  should 
not  be  allowed  to  go  to  school  or  mingle  with 
the  unprotected  until  two  weeks  after  the  com- 
pletion of  desquamation. 

SICK-ROOM  FOR  CONTAGIOUS 
DISEASES 

QUARANTINE 

A  child  ill  with  a  contagious  disease  should 
always  be  isolated,  whether  there  are  unpro- 
tected children  in  the  family  or  not.  Quaran- 
tine can  be  carried  out  only  when  the  child  is 
placed  in  a  room  alone  with  the  nurse  or 
mother,  and  neither  allowed  to  leave  the  room 
or  in  any  way  to  come  in  contact  with  other 
members  of  the  family.  If  possible  the  room 
should  be  on  the  top  floor  of  the  house.  The 
furniture  should  be  of  the  simplest, — no  fancy 
curtains  and  no  upholstery.  A  perfectly  bare 


i92  The  Sick-Room 

floor  is  best.  If  two  nurses  are  required,  two 
isolating  rooms  will  be  necessary,  one  to  be 
used  as  a  sleeping-room.  The  meals  should  be 
carried  on  a  tray  and  placed  upon  a  chair  out- 
side the  closed  door  of  the  isolating  room.  The 
dishes  containing  the  food  are  to  be  removed 
by  the  person  isolated.  After  use,  before 
returning  the  dishes  to  the  chair  outside  the 
door,  they  should  be  placed  for  five  minutes 
in  boiling  water.  Only  wash  goods  should 
be  worn  by  the  attendants,  and  their  clothing, 
with  bed  linen  when  changed,  should  be  placed 
in  boiling  water — one  ounce  of  carbolic  acid 
to  two  gallons  of  water — before  it  is  sent  to 
the  laundry. 

When  other  members  of  the  family  are  al- 
lowed to  go  at  will  into  and  out  of  the  isolating 
room,  the  value  of  the  quarantine  is  practically 
lost.  If  the  illness  is  of  a  serious  nature,  such 
as  scarlet  fever  or  diphtheria,  the  other  chil- 
dren of  the  family  should  be  sent  to  other 
quarters;  particularly  should  this  be  done  if 
the  family  occupy  an  apartment. 

DISINFECTANT  DRUGS 

The  erroneous  views  possessed  by  many 
concerning  disinfection  often  result  in  much 


The  Sick-Room  193 

harm.  Too  many  are  satisfied  by  the  use  of 
disinfectant  solutions  and  drugs  at  the  expense 
of  cleanliness.  Any  agent  that  will  destroy 
germs  is  a  disinfectant.  Disinfection  really 
means  cleanliness.  Disinfectants  can  never 
supplant  hot  water,  common  yellow  soap,  and 
a  nail-brush.  Dipping  the  hands  into  a  solu- 
tion of  carbolic  acid  or  bichloride  of  mercury 
will  not  make  them  clean,  much  less  sterile. 
Sprinkling  either  of  these  substances  upon  the 
floor  will  not  clean  the  floor  or  be  of  one  par- 
ticle of  service.  Scrubbing  the  floor  of  the 
sick-room  once  a  day,  using  hot  water,  sapolio, 
and  a  stiff  brush,  will  do  more  to  prevent  the 
circulation  of  the  germ-laden  dust  than  any 
disinfectant  which  can  be  used.  I  recently 
saw  a  young  mother  change  the  baby's  napkin, 
immediately  after  which,  with  hands  un- 
touched by  soap  or  water,  she  very  carefully 
washed  out  the  baby's  mouth  with  a  boracic 
acid  solution !  The  young  mother  was  anxious 
to  do  her  full  duty  by  the  child,  but  had  never 
learned  the  rudiments  of  disinfection. 

Disinfectant  solutions  and  drugs  are  of 
much  service  when  used  after  a  thorough 
scrubbing  with  hot  water,  soap,  and  brush, — 
never  before. 

13 


194  Disinfection 

DISINFECTION  AFTER  CONTAGIOUS 
DISEASES— FUMIGATION 

Before  being  allowed  to  resume  his  place 
in  the  family,  the  child  who  has  recovered 
from  a  contagious  disease  should  be  given  a 
tub-bath,  with  a  vigorous  scrubbing  with  soap 
and  warm  water.  The  hair  should  be  washed 
with  a  i  to  2000  solution  of  bichloride  of  mer- 
cury, and  the  child  dressed  in  fresh  clothing 
outside  the  sick-room. 

The  soiled  clothing  and  the  bedding  which 
can  be  washed  should  be  put  into  a  solution 
of  one  ounce  of  carbolic  acid  to  two  gallons 
of  water.  'The  vessel  should  be  covered  and 
removed  to  the  laundry  and  the  clothing  boiled 
thirty  minutes.  The  bedding  and  such  articles 
as  cannot  be  washed  should  be  spread  over  the 
furniture  in  readiness  for  fumigation. 

The  windows  and  doors  must  be  closed  and 
sealed,  when  the  room  can  be  fumigated  with 
sulphur  or  formalin.  If  sulphur  is  used,  three 
pounds  of  roll  sulphur  are  required  by  the 
New  York  Health  Department  for  every  thou- 
sand cubic  feet  of  air  space.  The  sulphur  is 
placed  in  an  iron  vessel  which,  as  a  precaution 
against  fire,  should  stand  on  a  large  piece  of 


Fumigation  195 

tin  or  zinc.  Alcohol  is  poured  over  the  sul- 
phur and  ignited,  after  which  the  room  should 
not  be  opened  for  twenty- four  hours.  If  the 
air  in  the  room  can  be  charged  with  a  moderate 
amount  of  vapor  from  an  open  vessel  on  a 
stove  or  radiator,  the  sulphur  disinfection  will 
be  more  complete.  Formalin  acts  as  a  much 
better  disinfectant  and  is  far  less  objectionable 
than  sulphur.  Formalin  candles  for  disinfect- 
ing purposes  may  be  found  in  all  drug  stores. 
After  the  fumigation,  the  carpet  or  rugs, 
mattresses  and  pillows,  are  taken  charge  of 
by  the  health  authorities  in  the  larger  cities, 
steamed,  and  returned  in  two  or  three  days 
free  of  expense  to  the  owner.  Otherwise  such 
articles  should  be  sent  to  the  cleaner  and  the 
mattresses  and  pillows  re-covered.  The  floor 
of  the  room  and  the  woodwork  should  be 
scrubbed  with  hot  water,  brush,  and  soap. 
When  dry  they  should  be  washed  with  a  I  to 
2000  solution  of  bichloride  of  mercury.  The 
furniture  should  also  be  washed  with  the 
bichloride  solution.  If  the  walls  are  papered, 
they  should  be  wiped  with  cloths  moistened 
with  this  solution;  but  it  is  better  to  have  the 
room  re-papered.  If  the  walls  are  painted, 
they  should  be  washed  with  the  solution.  If 


196        The  Delicate  Child 

the  walls  can  be  newly  papered,  painted,  or 
kalsomined,  much  greater  security  will  be  en- 
joyed by  the  future  occupant. 

THE  DELICATE  CHILD 

In  work  among  children  one  frequently 
meets  with  those  who,  while  they  cannot  be 
said  to  be  suffering  from  any  disease  or 
pathologic  condition,  yet  are  inferior  in 
physical  development,  lack  endurance,  and 
possess  poor  resisting  powers.  They  are 
often  under  height,  always  under  weight,  and, 
in  short,  have  so  many  characteristics  in  com- 
mon that  they  constitute  a  class  by  themselves, 
and  as  such  warrant  our  attention. 

Normal  development. — The  average  child, 
at  the  various  periods  of  early  life,  conforms 
with  a  certain  degree  of  regularity  to  the 
physical  development  which  by  long  asso- 
ciation we  have  come  to  regard  as  normal. 
Thus  a  standard  may  be  said  to  have  been  es- 
tablished, and  it  is  up  to  this  standard  4hat  we 
expect  the  growing  child  to  measure.  (See 
page  9.)  This  is  what  we  look  upon  as 
the  average  of  physical  development.  A 
few  children  exceed  these  requirements: 


The  Delicate  Child         19? 

they  are  stronger  and  larger  at  the  sixth 
month  than  the  average  child  at  the  ninth 
month.  Again,  older  children  at  the  fourth  or 
fifth  year  are  in  every  way  equal  to  their  nor- 
mal playmates  a  year  or  two  older. 

Abnormal  development. — On  the  other  hand, 
there  are  children  who  are  born  with  a  re- 
duced vitality,  or  who,  through  faulty  man- 
agement, usually  in  relation  to  feeding, 
acquire  a  reduced  vitality.  Semi-invalid 
adults  almost  invariably  beget  semi-invalid 
children.  If  the  parents  are  of  average  health 
and  of  good  habits,  and  the  debilitated  condition 
of  the  child  is  due  to  faulty  management  and 
nutritional  errors,  the  result  of  proper  dietetic 
and  hygienic  management  is  usually  prompt 
and  satisfactory.  With  the  persistently  deli- 
cate, the  offspring  of  physically  enfeebled 
parents,  the  results  are  less  satisfactory,  but 
improvement  is  always  possible. 

Management. — By  proper  regulation  of  the 
habits  of  a  delicate  child,  as  regards  all  the 
details  of  his  daily  life,  a  far  better  adult  is 
produced  than  if  no  such  effort  had  been  made. 
In  other  words,  a  diet  and  general  regime  of 
life  best  adapted  to  the  individual  in  question 
will  invariably  improve  the  physical  condition 


198        The  Delicate  Child 

of  that  individual.  This  applies  to  the  strong 
as  well  as  to  the  delicate,  to  the  growth  and 
development  of  the  young  of  the  lower  animals 
as  well  as  to  the  offspring  of  man.  It  is  the 
poorly  developed,  delicate  child  that  we  are 
particularly  to  consider — the  undersized,  frail, 
small-boned,  under-weight  child,  whose  appe- 
tite is  persistently  poor  or  capricious,  who 
sleeps  poorly,  tires  easily,  is  usually  constipated, 
who  is  subject  to  catarrhal  conditions  of  the 
respiratory  tract,  and  whose  powers  of  re- 
sistance generally  are  diminished.  In  not  every 
delicate  child  will  all  these  symptoms  be  found. 
Under-weight  and  one  or  more  of  the  other 
conditions  referred  to  will  usually  be  present. 
On  assuming  the  management  of  one  of 
these  children  it  is  absolutely  necessary  to  make 
a  thorough  examination,  followed  in  some  in- 
stances by  a  few  weeks'  observation,  in  order 
to  become  acquainted  with  the  case  in  its  indi- 
vidual aspects,  to  learn  idiosyncrasies,  and  to 
eliminate  the  factor  of  actual  disease  as  a 
causative  agent.  When  we  demonstrate  to 
our  satisfaction  that  the  child  is  free  from  such 
diseases  as  tuberculosis,  kidney  disease,  and 
malaria;  when  we  have  eliminated  by  properly 
directed  treatment  all  causes,  such  as  adenoids, 


The  Delicate  Child        199 

phimosis,  adherent  clitoris,  vaginitis,  or  parasi- 
tic and  irritant  skin  lesions,  which  may  have 
had  a  deterrent  influence  upon  growth;  and 
when  we  have  satisfied  ourselves  as  to  the 
actual  condition  of  our  patient,  we  are  in  a 
position  to  lay  down  definite  rules  of  manage- 
ment. 

Every  child  has  a  distinct  function  to  per- 
form. As  soon  as  he  is  born  he  is  confronted 
with  a  serious  problem — the  problem  of 
growth,  physical  and  mental.  Inasmuch  as 
this  growth  and  development  depend,  above 
all  things,  upon  a  properly  adapted  food  sup- 
ply, it  must  be  our  first  step  to  provide  such 
nutriment  as  will  be  most  conducive  to  it.  As 
growth  takes  place  in  all  parts  of  the  body 
through  cellular  activity,  the  nutritive  elements 
which  support  cell  proliferation  must  be  im- 
portant constituents  of  the  diet,  and  among 
these  the  proteids  are  of  prime  importance; 
hence  in  the  management  of  these  children  a 
point  to  be  remembered  in  the  adaptation  of  the 
food  is  the  necessity  of  feeding  as  rich  a 
proteid  as  the  child  can  assimilate.  The 
younger  the  child,  the  greater  the  necessity 
for  growth. 

Regular   weighings   necessary. — An    infant 


200        The  Delicate  Child 

should  be  weighed  at  regular  intervals,  and 
if  under  one  year  of  age,  should  not  be  con- 
sidered as  doing  even  passably  well  if  not  gain- 
ing at  least  four  ounces  weekly.  When  a  baby 
remains  stationary  in  weight  its  development 
is  invariably  abnormal.  When  stationary  or 
when  only  a  slight  gain  of  one  or  two  ounces 
weekly  is  made,  we  will  always  find  after  a 
few  weeks  that  there  is  malnutrition,  in  spite 
of  the  apparent  gain,  as  will  be  evidenced  by 
the  symptoms  of  beginning  rickets — anaemia, 
the  characteristic  bone  changes,  flabby  muscles, 
and  a  tendency  to  disease  of  the  mucous  mem- 
branes. Delicate  infants  should  be  weighed 
daily  at  first ;  then,  as  improvement  takes  place, 
at  intervals  of  two  or  more  days,  but  never 
less  frequently  than  once  a  week,  if  under  one 
year  of  age,  no  matter  how  vigorous  they  may 
become.  The  weighing  keeps  us  directly  in 
touch  with  the  child's  condition,  but  since  the 
increase  may  be  in  fat  alone,  an  occasional  ex- 
amination of  the  child  stripped  is  necessary 
to  tell  us  whether  there  is  substantial  growth 
in  bone  and  muscle. 

Feeding  delicate  infants. — When  it  is  dem- 
onstrated that  a  child  will  not  thrive  on  the 
breast  of  the  mother,  another  breast  should  be 


The  Delicate  Child        201 

substituted,  or  an  adapted  high-proteid  cows' 
milk  should  form  the  diet  in  part  or  in  whole. 
If  the  child  is  bottle-fed  and  it  is  demonstrated 
that  proper  growth  and  development  are  im- 
possible on  cow's  milk,  on  account  of  proteid 
incapacity,  then  a  wet-nurse  should  be  secured. 

When,  after  the  first  year,  more  liberal  feed- 
ing is  allowed,  the  necessity  for  a  high  proteid 
in  the  food  selected  is  as  urgent  as  before. 
This  applies  to  those  children  who  are  brought 
to  us  showing  evidences  of  late  malnutrition, 
as  well  as  to  those  whom  we  have  had  under 
our  care  from  early  infancy. 

An  important  element  in  the  diet  up  to  the 
third  year,  is  milk.  Unfortunately,  many  de- 
bilitated children  have  a  very  poor  capacity 
for  fat  assimilation.  When  given  full  milk 
in  as  small  an  amount  as  one  pint  daily,  they 
often  develop  foul  breath,  coated  tongue,  and 
loss  of  appetite,  or  they  suffer  from  frequent 
attacks  of  acute  indigestion.  The  milk  is 
necessary,  not  because  of  the  fat,  which  can 
easily  be  dispensed  with,  but  because  of  the 
high  percentage  of  proteid  which  it  contains — 
from  three  to  four  per  cent.  When  this  fat 
incapacity  exists,  the  milk  is  said  to  "disagree," 
but  skimmed  milk  will  be  taken  without  incon- 


202        The  Delicate  Child 

venience.  Enough  sugar  may  be  added  to 
bring  the  percentage  up  to  seven,  in  order  that 
it  may  replace  the  fat,  for  fuel.  Skimmed 
milk  with  sugar  added  furnishes  a  food  of 
no  mean  order.  Too  much  milk,  however, 
must  not  be  given.  When  large  quantities, 
more  than  one  quart  daily,  are  taken,  the  desire 
for  more  substantial  nourishment,  such  as 
eggs,  meat,  and  cereals,  is  removed. 

At  the  completion  of  the  first  year,  keeping 
in  mind  a  high  proteid,  begin  with  scraped 
beef,  at  first  one  teaspoonful  once  a  day,  in 
addition  to  the  cereal  and  milk.  If  this  is  well- 
borne,  and  it  usually  is,  a  teaspoonful  may  be 
given  twice  a  day,  and  later  three  times  a  day. 
It  may  be  given  immediately  before  the  bottle- 
feeding.  Eggs  should  be  brought  into  use 
from  the  twelfth  to  the  fifteenth  month.  At 
first  one-half  an  egg,  boiled  two  minutes,  is 
given  mixed  with  bread-crumbs.  If  well  borne, 
a  whole  egg  may  be  allowed.  The  cereals  used 
should  be  those  most  rich  in  vegetable  protein, 
such  as  oatmeal,  containing  16  per  cent,  of 
proteid,  "dried  peas,  20  per  cent,  of  proteid,  and 
dried  beans,  containing  24  per  cent,  of  proteid. 
The  peas,  beans,  and  lentils  should  be  given  in 
the  form  of  a  puree.  . 


The  Delicate  Child        203 

Diet  after  the  first  year. — If  the  child  during 
the  second  year  has  an  indifferent  appetite, 
reduce  the  quantity  of  milk;  never  al- 
low more  than  one  pint  of  milk  daily 
for  the  first  week  or  two  under  treat- 
ment. Many  delicate  children  who  apply 
for  treatment  after  the  first  year  of  age 
have  been  subjected  to  as  grave  errors  in  diet 
as  are  seen  among  the  bottle-fed.  Starch  foods 
and  milk  oftentimes  furnish  the  only  means 
of  nutrition  up  to  the  fourth  or  fifth  year,  the 
starch  used  being  generally  in  the  form  of 
bread,  crackers,  and  indifferently  cooked 
cereals.  In  one  case  four  quarts  of  milk  were 
taken  daily  by  a  boy  of  seven  years. 

It  will  be  seen  that  it  is  our  aim  in  this  class 
of  children — the  delicate,  undersized,  slow- 
growing  class — to  give  as  liberal  a  nitroge- 
nous nourishment  as  is  compatible  with 
the  digestive  capacity  of  the  patient.  But 
if  the  child  has  had  rheumatism,  or  if 
there  is  a  tendency  to  lithiasis,  the  use 
of  a  large  amount  of  meat  is  contra- 
indicated.  It  is  in  such  children  that  the  high- 
proteid  cereals  are  particularly  valuable.  In 
a  general  way,  from  early  life  the  diet  of  the 
delicate  child  should  consist  of  milk,  suitably 


204        The  Delicate  Child 

adapted,  with  highly  nitrogenous  cereal  added, 
when  permissible.  Many  delicate  children  of 
the  "runabout"  age  who  cannot  digest  milk 
containing  4  per  cent,  of  fat  will  easily  digest 
butter  fat  when  spread  on  bread  or  potatoes. 
In  this  way  I  often  use  it  to  supply  fuel  to  act 
as  a  proteid-sparer.  Oatmeal-water  or  oat- 
meal-jelly, mixed  with  the  milk,  should  be 
ordered  at  the  seventh  month.  When  age  al- 
lows, the  addition  of  raw  meat,  poultry,  eggs, 
and  purees  of  dried  peas,  beans,  and  lentils 
should  be  given.  Boxed  "ready  to  serve" 
cereals  are  never  given;  raw* cereals  are  used, 
which  are  cooked  three  hours.  While  a  high- 
proteid  diet  is  desirable,  other  things  are  neces- 
sary. Green  vegetables,  animal  fats,  the 
ordinary  cereals,  cooked  and  raw  fruits,  are  re- 
quired to  furnish  the  necessary  acids  and  salts, 
as  well  as  the  necessary  variety.  In  short,  the 
ideal  diet  for  a  delicate  child  is  that  combina- 
tion of  food  which,  while  imposing  the  least 
burden  upon  the  digestive  organs,  supplies  the 
body  with  material  exactly  sufficient  for  its 
needs,  and  such  a  food  must  be  rich  in  nitro- 
gen. (See  dietary,  page  71.) 

Baths. — On  account  of  the  fear  that  a  deli- 
cate child  may  take  cold,  the  bath  is  often 


The  Delicate  Child         205 

omitted.  Every  child,  both  the  well  and  the 
delicate,  after  the  second  week  should  be 
tubbed  daily.  The  delicate  particularly  require 
it.  The  brine  bath  (page  115)  is  usually  ad- 
vised. The  best  time  for  giving  the  bath  is  at 
bedtime,  and  in  order  to  avoid  all  chance  of 
exposure  the  temperature  of  the  room  should 
be  elevated  to  80°  F.  The  temperature  of  the 
water  may  vary.  It  should  never  be  above  95° 
F.  except  for  very  delicate  young  children  in 
whom  there  is  a  tendency  to  a  subnormal  tem- 
perature. Even  in  these  cases  the  temperature 
of  the  bath  should  never  be  higher  than  the 
temperature  of  the  body.  In  the  frail  and  in 
the  very  young  the  bath  should  not  be  con- 
tinued over  five  minutes.  In  older  children,, 
those  of  eighteen  months  or  over,  if  the  physi- 
cal conditions  allow,  a  distinct  advantage  will 
be  gained  by  a  reduction  of  the  temperature 
of  the  bath  while  the  child  is  in  the  water.  An 
immersion  in  water  at  90°  F.  followed  by  a 
gradual  reduction  during  the  space  of  five  or 
six  minutes  to  70°  F.  should,  upon  brisk  rub- 
bing, be  followed  by  a  quick  reaction.  If  the 
reaction  is  not  good,  if  the  extremities  are  cold 
and  are  slow  in  becoming  warm,  the  reduction 
in  the  temperature  should  be  less  or  none  at  all. 


206        The  Delicate  Child 

In  the  very  poorly  nourished,  a  reduction  below 
80°  F.  should  not  be  attempted.  Following  the 
drying  process,  primarily  for  the  benefit  of 
the  massage,  goose  oil  or  olive  oil  should  be 
rubbed  into  the  skin  over  the  entire  body  for 
from  five  to  ten  minutes.  The  bath  and  the 
massage  inunction,  besides  favorably  influenc- 
ing nutrition,  are  a  very  effective  means  of 
inducing  sleep. 

Fresh  air. — Delicate  children  are  usually  de- 
prived of  a  proper  amount  of  fresh  air,  for  the 
same  reason  that  they  are  insufficiently  bathed 
— the  fear  of  making  them  ill.  All  children 
need  an  abundance  of  fresh  air,  both  in  illness 
and  in  health.  The  robust  and  the  delicate  re- 
quire it,  and  to  the  delicate  it  is  much  more 
essential  than  to  the  robust.  As  many  hours 
daily  as  practicable  should  be  spent  out  of  doors. 
The  time  thus  spent  depends  upon  the  season 
of  the  year  and  the  residence  of  the  child, 
whether  in  the  city  or  the  country.  In  the  city, 
during  the  colder  months  with  pleasant 
weather,  the  child  should  spend  at  least  five 
hours  daily  in  the  open  air,  dividing  the  day 
into  two  outing  periods — from  9  to  1 1 130  in 
the  morning  and  from  2  to  4 130  in  the  after- 
noon. On  very  cold  days,  20°  F.  or  below, 


The  Delicate  Child        207 

on  stormy  days,  and  on  days  with  very  high 
winds,  the  child  is  given  his  airing  indoors. 
He  is  dressed  as  for  out  of  doors,  placed  in  his 
carriage,  and  left  in  a  room,  the  windows  on 
one  side  of  the  room  being  open.  Not  infre- 
quently during  February  and  March  delicate 
children  will  be  prevented  from  going  out  of 
doors  for  several  consecutive  days.  If  some 
means  for  a  daily  systematic  indoor  airing  is 
not  provided,  these  children  will  often  go  back- 
ward, no  matter  how  excellent  the  other  man- 
agement. The  first  symptoms  are  loss  of  ap- 
petite and  the  ability  to  assimilate  the  food. 
In  my  private  work  among  marasmus  cases, 
the  child  is  placed  in  the  baby-carriage  or  in  a 
basket  and  allowed  to  rest  before  an  open 
window  for  ten  or  twelve  hours  of  every 
twenty- four,  with  a  hot-water  bottle  at  his  feet. 
Here  he  is  fed,  being  removed  only  tem- 
porarily to  warmer  quarters  for  a  change  of 
napkins.  I  have  several  roof  gardens  in  opera- 
tion. A  boy  patient  nine  months  of  age  has 
been  in  the  street  only  once  in  four  months, 
then  only  in  going  to  church  to  be  baptized. 

Sleep.  —  The  delicate  child  requires  no 
more  sleep  than  does  the  strong,  and  the  rules 
governing  this  matter  at  the  various  periods 


208        The  Delicate  Child 

of  life  are  the  same  both  for  the  strong  and 
for  the  weak.  (See  Sleep,  page  282.)  The 
sleeping-room  of  the  delicate  child  should  al- 
ways communicate  with  the  open  air  by  a  win- 
dow, either  directly  or  through  an  adjoining 
room.  A  satisfactory  method  of  ventilation 
is  by  the  window-board  (page  16).  The  child 
should  occupy  the  room  alone,  if  possible, 
sharing  it  neither  with  an  adult  nor  another 
child.  This  applies  to  all  ages,  but  is  particu- 
larly necessary  after  the  second  year. 

The  nursery. — The  temperature  of  the 
nursery,  day  or  night,  should  never  be  above 
70°  F.,  during  the  colder  months,  and  in  the 
case  of  the  very  young,  or  in  those  who  are 
difficult  to  keep  covered,  it  should  not  go  be- 
low 65°  F.  at  night. 

Delicate  children  of  the  "runabout"  age  are 
very  susceptible  to  colds.  In  the  management 
of  such  children  it  is  necessary  to  use  every 
precaution  against  exposure.  The  most  fre- 
quent way  of  exposing  a  child  to  cold  is  by 
allowing  him  to  sit  on  the  floor.  To  keep  the 
child  of  from  ten  months  to  three  years  of  age 
off  the  floor  during  the  winter  months,  and 
thereby  to  eliminate  this  means  of  exposure, 
is  a  very  difficult  matter.  In  fact  with  active 


The  Delicate  Child        209 

children,  learning  to  walk,  or  who  have  just 
learned  to  walk,  it  is  practically  impossible  un- 
der the  usual  conditions.  During  the  colder 
months  there  is  always  a  current  of  cold  air 
near  the  floor,  and  allowing  the  child  to  creep 
in  winter,  even  if  the  floor  is  protected  by  rugs 
and  carpets,  is  one  of  the  surest  ways  of  per- 
mitting him  to  take  cold.  If  he  is  allowed  to 
walk  on  the  floor  he  is  soon  very  sure  to  sit 
down.  If  he  is  not  allowed  to  creep  and  walk 
about  at  will,  he  will  not  get  the  proper  exer- 
cise and  will  show  faulty  development.  For 
such  cases  I  have  found  the  exercise  pen  of 
immense  service  (see  Fig.  21.).  After  being 
dressed,  washed,  and  fed,  the  child  is  placed 
in  the  pen,  on  a  rug  if  desired.  Toys  are  given 
him  and  the  door  is  closed.  He  can  now  roam 
about  at  will,  stand  up,  sit  down,  creep,  or  walk 
without  the  slightest  danger  from  drafts. 

Influence  of  climate. — Much  has  been  writ- 
ten regarding  the  influence  of  climate  in  the 
type  of  case  we  are  considering.  According 
to  my  observation,  this  matter  does  not  deserve 
the  attention  it  has  received.  The  city  child 
in  a  well-to-do  family  is,  as  a  rule,  better  off 
for  eight  months  of  the  year  in  his  own  home 
with  its  usual  conveniences.  The  benefits  at- 


210         The  Delicate  Child 

tributed  to  change  in  climate  are  usually  the 
result  of  a  change  not  of  climate  but  to  more 
fresh  air,  which  is  afforded  by  the  larger 
rooms  of  the  hotel,  with  its  loosely  constructed 
doors  and  windows;  and  since  the  parent  is 
desirous  that  the  child  shall  receive  the  full 
benefit  of  the  change,  he  is  kept  in  the  open 
air  for  a  much  longer  time  than  when  at  home. 
The  air  at  such  a  place  is  more  expensive,  and 
consequently  more  appreciated  than  the  air  at 
home.  With  sufficient  heat  and  proper  ventila- 
tion, we  may  make  our  own  climate.  It  is  not 
to  be  denied,  however,  that  a  change  of  resi- 
dence for  a  few  weeks  from  New  York  to 
Lakewood  or  Atlantic  City  during  March  and 
April  is  sometimes  of  advantage. 

From  the  first  of  June  to  the  first  of  Octo- 
ber the  delicate  child  should  not  remain  in  New 
York  City.  The  humidity  and  the  heat  which 
may  prevail  for  protracted  periods  during  this 
time  render  it  unsafe,  particularly  during  July 
and  August.  The  seashore  for  the  entire  sum- 
mer is  not  to  be  advised.  The  children  whom 
I  have  sent  inland  to  the  country  and  to  the 
mountains  have,  as  a  rule,  returned  in  the  au- 
tumn in  a  much  better  physical  condition  than 
those  who  spent  the  summer  by  the  sea. 


The  Delicate  Child        211 

Clothing. — Thin,  poorly  nourished  children 
require  more  clothing  than  do  those  physi- 
cally normal.  A  fairly  good  index  as  to 
whether  a  child  is  sufficiently  clad  is  the  condi- 
tion of  his  lower  extremities.  The  forearm 
and  hand  cannot  be  relied  upon.  The  legs  and 
feet  of  every  child  should  always  be  warm  to 
the  touch. 

As  to  the  nature  of  the  clothing. — A  mixture 
of  silk  and  wool  next  to  the  skin  is  most  de- 
sirable. As  a  second  choice  a  mixture  of  wool 
and  cotton  is  used.  The  linen  mesh,  often 
useful  in  the  vigorous  "runabout,"  is  not  to 
be  advised  in  the  delicate. 

Exercise. — Moderate  exercise  is  to  be  en- 
couraged. But  it  should  never  be  allowed 
to  the  point  of  fatigue.  In  large  cities  all  deli- 
cate "runabouts"  from  three  to  five  years  of 
age  should  be  allowed  to  walk  not  more  than 
six  blocks  in  going  to  the  playgrounds.  If  the 
distance  is  greater,  the  child  should  ride  part 
of  the  way,  play  or  walk  for  a  time,  and  then 
be  placed  in  the  carriage  or  cart  and  ride  home. 
Younger  children,  two  or  three  years  of  age, 
should  be  wheeled  both  ways  and  taken  out  at 
the  park  for  a  run  when  the  weather  conditions 
permit. 


212         The  Delicate  Child 

Midday  nap. — Every  day  after  the  midday 
meal  the  child,  regardless  of  age,  whether  two 
years  or  six,  should  be  undressed  and  put  to 
bed  for  two  hours.  He  should  be  left  alone 
in  the  room,  and  whether  he  sleeps  or  not  he 
should  remain  in  bed  for  the  two  hours. 

Entertainment. — Entertaining  play  is  neces- 
sary, but  every  kind  of  excitement,  such  as 
children's  parties,  emotional  plays  at  the 
theatre,  and  rough  play  with  older  children, 
should  be  avoided. 

Education. — The  delicate  child  under  eight 
years  of  age  should  be  taught  only  to  the  ex- 
tent of  strict  obedience  and  good  habits.  Other 
than  this  he  should  be  a  little  animal.  There 
should  be  no  teaching  in  the  ordinary  sense 
of  the  term,  no  mental  stimulation,  until  the 
child  is  physically  able  to  bear  it.  When 
school-work  begins,  which  in  this  class  of 
children  should  never  be  before  the  eighth 
year,  the  studies  should  be  made  easy  and  the 
school  hours  short.  Such  children  should 
never  be  crowded.  I  usually  direct  that  they 
attend  only  the  morning  session. 

The  delicate  child  should  be  carefully 
watched  from  the  time  it  comes  into  our  hands 
until  it  reaches  the  normal  or  until  the  period 


Premature  and  Weak  Infants  213 

of  development  is  completed.  While  the 
scheme  of  management  as  outlined  will  not 
always  be  attended  with  brilliant  results,  it 
will  not  be  in  vain.  Many  lives  will  be  saved, 
and  as  a  result  of  the  increased  acquired  re- 
sistance, stronger  men  and  women  will  be 
added  to  the  race  than  would  otherwise  have 
been  possible. 

PREMATURE    AND     CONGENITALLY 
WEAK  INFANTS 

There  are  comparatively  few  infants  born 
before  the  completion  of  the  twenty-eighth 
week  of  pregnancy  that  survive  the  first  year. 
Reported  cases  of  survival  of  those  born  be- 
fore that  time  are  usually  unreliable,  as  they 
seldom  take  the  child  beyond  the  third  month. 
The  prognosis  is  influenced  by  the  factors 
causing  the  premature  birth. 

Management. — In  the  management  of  the 
premature  and  delicate  newly  born  there  are 
three  points  to  be  considered — the  air  the  child 
gets  to  breathe,  the  nourishment,  and  the  main- 
tenance of  bodily  heat.  It  is  also  to  be  remem- 
bered that  we  are  dealing  with  an  undeveloped 
body  which  is  not  ready  for  the  environment 


214  Premature  and  Weak  Infants 

in  which  it  is  placed.  The  premature 
baby  should  be  handled  only  when  neces- 
sary, and  then  in  the  gentlest  manner.  Bath- 
ing is  often  best  omitted  for  the  first  few 
weeks,  oil  being  used  for  cleansing  purposes. 
Because  of  the  undeveloped  parenchyma  of 
the  lungs  unusually  good  fresh  air  is  required. 
Because  of  the  undeveloped  heat-centres  the 
body-heat  of  the  premature  infants  is  quickly 
lost  and  must  be  maintained  by  artificial  means. 
The  stomach  is  small  and  the  digestive  proc- 
esses are  undeveloped  and  weak,  so  that  the 
nourishment  should  be  of  the  most  easily  as- 
similable character. 

Incubators. — The  maintenance  of  heat  is  of 
the  utmost  importance.  For  this  purpose 
incubators  and  their  various  modifications 
have  been  used  from  time  to  time.  My  experi- 
ence with  incubators  has  been  unsatisfactory. 
They  may  by  careful  watching  maintain  an 
even  temperature,  but  all  that  I  have  used  have 
been  defective  in  supplying  fresh  air  to  the 
child.  My  incubator  babies  have  usually  done 
badly.  Removal  from  the  incubator  was  neces- 
sary. 

The  electrotherm. — If  the  electrotherm 
(Fig.  12)  is  not  at  hand,  the  padded  crib  with 


Premature  and  Weak  Infants  215 

the  child  wrapped  in  cotton  and  surrounded 
by  hot-water  bottles  is  the  best  means  of  main- 
taining the  temperature.  A  thermometer 
should  rest  between  the  cotton  and  the  bed- 
clothing  as  a  guide  to  the  nurses  in  the  use  of 


FIG.    12.      THE   ELECTROTHERM 

the  hot-water  bottles.  Ordinarily  this  should 
register  from  85°  to  95°  F.,  depending  upon 
the  temperature  of  the  child,  whose  rectal  tem- 
perature should  at  first  be  taken  frequently. 
If  there  is  a  tendency  for  his  temperature  to 
be  greatly  reduced — below  95°  F. — more  ex- 
ternal heat  will  be  necessary  than  if  the  tem- 
perature were  97°  or  98°  F.  The  best  device 


216  Premature  and  Weak  Infants 

among  those  which  I  have  had  an  opportunity 
to  observe  for  maintaining  artificial  heat  is  the 
electrotherm  advocated  and  described  by  Holt, 
Diseases  of  Infancy  and  Childhood,  1906. 

"These  small  heaters  are  attached  to  an 
electric  fixture,  like  a  drop-light.  A  convenient 
size  is  from  ten  to  fifteen  inches.  It  is  placed 
between  two  or  three  thicknesses  of  blankets, 
upon  which  the  infant  lies  in  its  basket  or  crib. 
The  degree  of  heat  can  be  regulated  according 
to  the  amount  of  electricity  turned  on.  This 
mode  of  handling  premature  infants  has  been 
given  thorough  trial  at  the  Babies'  Hospital 
and  has  been  found  to  fulfil  the  indication, 
with  children  as  small  as  three  pounds  and  as 
young  as  seven  months,  quite  as  well  as  the  in- 
cubator, while  at  the  same  time  being  free  from 
its  dangers.  It  has  not  been  necessary  to  raise 
the  general  temperature  of  the  room.  These 
patients  when  kept  in  the  wards  at  an  ordinary 
temperature  have  maintained  an  even  bodily 
temperature  much  more  uniformly  than  with 
any  other  method  I  have  seen,  the  incubator 
included." 

A  mistake  often  made  in  the  management 
of  premature  and  delicate  infants  is  that  of 
providing  too  warm  air  for  respiration,  a  glar- 


Premature  and  Weak  Infants  217 

ing  defect  in  most  incubators.  The  best  means 
of  decreasing  a  delicate  child's  vitality  and  re- 
sistance and  increasing  his  chances  of  pulmon- 
ary infection,  is  to  supply  him  constantly  with 
air  at  80°  to  90°  F.  In  a  modern  house  the 
maintenance  of  this  temperature  usually  means 
an  absence  of  change  of  air  and  an  abundance 
of  bacteria.  The  patients  do  best  when  the  tem- 
perature of  the  air  they  breathe  is  from  70° 
to  72°  F. 

Necessity  of  breast-milk. — Breast-milk  for 
premature  infants  born  under  twenty-eight 
weeks  is  almost  a  necessity,  and  should  always 
be  procured  when  possible  for  all  premature 
children.  The  mother,  with  the  rarest  excep- 
tion, is  unable  to  supply  it,  so  that  a  wet-nurse 
should  be  secured.  In  selecting  a  wet-nurse 
for  a  premature  baby  it  is  advisable  to  take 
the  wet-nurse's  baby  also,  as  the  premature 
infant  may  not  be  able  to  nurse,  or  if  he  nurses 
he  will  not  take  all  the  milk.  Pumping  the 
breasts  of  a  wet-nurse  will  almost  invariably 
dry  them  up,  if  her  own  baby  is  not  with  her 
to  furnish  the  necessary  stimulation  of  nurs- 
ing. Sufficient  milk  may  be  removed  by  the 
breast-pump  to  supply  the  premature  infant  if 
he  is  unable  to  nurse,  and  the  wet-nurse's  baby 


218  Premature  and  Weak  Infants 


will  empty  the  breast.  For  premature  babies 
who  refuse  the  breast  or  are  unable  to  take  a 
nipple,  the  Breck  feeder  (Fig. 
13)  may  be  used  as  a  means  of 
giving  nourishment,  or  gavage, 
forced  feeding  with  a  tube,  may 
be  brought  into  use.  This  I  have 
been  obliged  to  resort  to  in  sev- 
eral cases.  The  Breck  feeder 
consists  of  a  graduated  glass 
tube,  narrowed  at  one  end.  Over 
this  end  is  placed  a  small  rubber 
nipple,  the  other  end  being  closed 
by  a  flexible  rubber  cap.  Draw- 
ing on  the  nipple  is  aided  and  en- 
couraged by  pressure  on  the  air- 
filled  cap.  If  the  breast-milk 
proves  too  strong  it  may  be 
diluted  with  equal  parts  of  a  6 
per  cent,  sugar  solution,  one 
ounce  of  the  mixture  being  given 
at  first  at  intervals  of  two  hours. 

FIG.    13.      THE  c        «•  , 

BRECK  FEEDER  Ten  to  twelve  feedings  may  be 
given  in  the  twenty- four  hours, 
the  amount  depending  upon  the  child's  diges- 
tive ability. 

Feeding  other  than  the  breast. — If  human 


Glands  219 

milk  is  not  obtainable,  whey  made  from  whole 
milk  may  be  given,  or  one  ounce  of  gravity 
cream  may  be  given  with  one  ounce  of  milk- 
sugar,  one  ounce  of  lime-water,  and  fourteen 
ounces  of  water.  Canned  condensed  milk,  one 
part,  to  from  24  to  30  parts  of  water,  may 
be  used  with  advantage  as  a  temporary  feed- 
ing measure  when  nothing  better  is  available. 
The  food  strength  is  increased,  the  intervals 
made  longer,  and  the  feeding  larger,  as  the 
patient  proves  able  to  assimilate  the  food. 

GLANDS 

ACUTE  ENLARGEMENT  OF  THE  GLANDS  OF 
THE  NECK 

A  mother  is  often  alarmed  by  the  sudden 
appearance  of  a  hard  swelling  in  the  neck  of 
one  of  her  children.  The  swelling  may  appear 
during  the  night  and  increase  greatly  in  size 
for  a  day  or  two,  when  it  may  be  as  large  as 
a  horse-chestnut.  Such  a  condition  is  due  to 
swollen  lymphatic  glands,  which  are  usually 
situated  just  behind  the  jaw  and  below  the 
ear.  Occasionally  the  swellings  may  appear 
in  the  soft  parts  under  the  jaw.  The  glands, 
in  the  performance  of  their  functions,  have 
become  infected  and  the  swelling  follows.  The 


220  Glands 

cause  of  the  infection  will  usually  be  found  in 
a  lesion  of  the  mouth  or  throat.  It  may  some- 
times be  traced  to  a  lesion  of  the  skin  in  the 
neighborhood  of  the  swelling.  Thus,  the 
source  of  infection  may  be  a  decayed  tooth,  a 
simple  abrasion  of  the  mucous  membrane,  or 
an  acute  inflammation  of  the  part,  such  as  ton- 
sillitis or  pharyngitis.  In  scarlet  fever  and  in 
diphtheria  the  glands  are  often  seriously  in- 
volved. The  glandular  enlargements,  how- 
ever, which  appear  suddenly,  independent  of 
serious  illness,  need  cause  no  great  anxiety. 
They  terminate  usually  in  one  of  two  ways : 
they  gradually  disappear  under  treatment,  or 
they  break  down  and  form  an  abscess  which 
requires  incision  and  drainage.  In  either  event 
complete  recovery  follows. 

If  the  swellings  occur  in  diphtheria  or  in 
any  other  infectious  disease,  they  may  con- 
stitute a  grave  complication.  With  their  first 
appearance,  apply  cold  compresses  to  the  parts 
constantly  until  the  physician  arrives. 

CHRONIC  ENLARGEMENT  OF  THE  GLANDS 
OF  THE  NECK 

The  lymphatic  glands  of  the  neck  may  be 
chronically  enlarged  as  a  result  of  tubercu- 


The  Skin  in  Health        221 

losis,  syphilis,  or  local  infections  from  the 
skin,  and  a  lowered  general  vitality. 

The  mother  usually  notices  a  slight  swelling 
of  the  parts,  which,  upon  touch,  gives  the  im- 
pression of  a  hard  round  body  immediately 
beneath  the  skin;  usually  several  of  these 
nodules  will  be  discovered.  They  often  extend 
in  chains  down  the  side  of  the  neck;  some- 
times both  sides  will  be  involved.  Bunches  of 
glands  may  also  appear  under  the  ear  and  at 
the  angle  of  the  jaw.  They  vary  in  size  from 
a  buckshot  to  a  butternut. 

Children  with  a  tendency  to  enlargement  of 
these  glands  should  be  constantly  under  medi- 
cal supervision. 

THE  SKIN  IN  HEALTH 

The  skin  of  an  infant  is  extremely  delicate 
and  great  care  is  required  to  keep  it  in  a 
healthy  condition.  The  secret  of  a  healthy 
skin  in  an  infant  is  in  proper  attention.  It 
must  be  kept  clean  and  dry.  After  the  daily 
bath,  in  which  no  ingredient  other  than  plain 
boiled  water  and  Castile  soap  should  enter,  the 
baby  must  be  carefully  dried  and  the  folds  of 
the  skin  and  flexures  of  the  joints  thoroughly 


222  Eczema 

powdered  with  equal  parts  of  oxide  of  zinc 
and  powdered  starch.  When  the  napkins  are 
soiled  they  should  be  changed  at  once  and  the 
parts  again  washed  and  powdered.  An  occa- 
sional sponging,  followed  by  a  generous  use  of 
powder  during  very  hot  weather,  will  often 
prevent  annoying  skin  affections,  such  as 
prickly  heat  and  eczema. 

ECZEMA 

Eczema,  a  catarrhal  inflammation  of  the 
skin,  is  a  disease  to  which  young  children  are 
very  susceptible.  It  appears  in  different  forms, 
which  means  that  there  are  several  varieties 
of  the  disease.  Any  portion  of  the  skin  sur- 
face may  be  involved.  The  parts  most 
frequently  affected  are  the  scalp,  cheeks,  fore- 
head, and  the  flexures  of  the  joints,  where  the 
skin  surfaces  come  in  contact.  The  cause  of 
eczema  may  be  from  within  or  without.  The 
external  causes  are  all  of  the  nature  of  irritants. 
A  baby's  skin  is  very  delicate,  and  trifling 
causes  will  often  produce  a  great  deal  of  in- 
flammation. Strong  soaps,  liniments,  a  sudden 
exposure  of  the  moist  skin  to  cold  air,  exces- 
sive perspiration,  insufficient  bathing,  dis- 
charge from  the  ear  or  nose,  all  may  cause  a 


Eczema  223 

local  irritation  and  produce  the  disease.  Al- 
lowing a  child  to  rest  in  a  soiled  napkin  is  a 
most  frequent  cause  of  eczema  of  the  buttocks, 
a  condition  which  is  elsewhere  referred  to. 
The  treatment  of  this  type  of  the  disease  re- 
solves itself  into  removing  the  cause  and  pro- 
tecting the  parts  by  means  of  a  suitable  oint- 
ment or  powder. 

Internal  causes. — Among  the  internal  causes 
indigestion  is  by  far  the  most  frequent.  It  is  not 
the  delicate  child  who  suffers  most  from 
eczema.  In  many  instances  the  robust  nurs- 
ling and  the  vigorous  bottle-fed  baby  are  the 
sufferers.  The  child  in  other  respects  appears 
well,  has  a  good  appetite,  is  bright  and  happy, 
and  shows  normal  development.  The  bright 
red  and  sometimes  weeping  area  on  each  cheek, 
and  the  itching,  scaly  forehead,  show  clearly 
that  something  is  wrong,  and  the  error  will 
be  found  in  the  gastro-intestinal  tract.  The 
food  in  some  respect  is  unsuitable,  not  being 
properly  adapted  to  the  child's  digestive 
capacity. 

Management  in  the  breast-fed. — In  the 
breast-fed,  regulation  of  the  life  of  the  mother 
as  regards  her  diet,  exercise,  and  bowel  func- 
tions will  often  effect  a  cure. 


224  Eczema 

The  bottle-fed. — In  the  bottle-fed,  an  ad- 
justment of  the  food  to  the  child's  age  and 
digestive  capacity  and  attention  to  the  daily 
bowel  evacuation  aids  materially  in  the  treat- 
ment. Constipation,  if  present,  must  be  re- 
lieved. Local  treatment  with  ointments, 
washes,  and  powders  are  all  of  little  value  if 
the  cause  of  the  disorder  is  not  removed.  The 
case  may  improve  temporarily  under  the  local 
treatment,  but  within  a  few  days  the  inflamma- 
tion reappears  in  full  force. 

Influence  of  fat  and  sugar. — An  excess  of 
sugar  and  fat  in  the  diet  or  an  incapacity  for 
the  substances  are  very  frequent  causes  of 
eczema  in  bottle-fed  children. 

Eggs  and  other  albumins,  both  animal  and 
vegetable,  may  cause  eczema  in  susceptible 
subjects. 

The  strait- jacket. — One  of  the  difficult  fea- 
tures of  treating  children  with  eczema  is  the 
tendency  for  the  child  to  scratch  the  involved 
parts.  This  not  only  keeps  up  the  trouble  in- 
definitely but  the  nails  are  often  the  carriers  of 
infection.  I  have  seen  not  only  severe  derma- 
titis, but  furunculosis  and  cellulitis  develop  in 
this  way.  One  of  the  best  means  of  preventing 
scratching  is  in  the  modified  strait-jacket  (see 


Eczema 


225 


Fig.  14).     The  jacket  is  made  of  muslin  and 
must  be  fitted  to  the  patient.     The  child  is 


FIG.    14.      STRAIT-JACKET 


slipped  into  the  jacket  feet  first.  The  opening 
A  encircles  the  thorax  directly  under  the  arms. 
The  opening  B  is  closed  about  the  neck  with 


FIG.    15.      STRAIT- JACKET  IN  POSITION 

the  attached  tapes.     The  cord  which  is  used 
to  close  the  end  of  the  skeves  may  be  tied 


15 


226 


Eczema 


to  the  sides  of  the  crib  or  pinned  to  the  bed- 
ding. Children  readily  accustomed  themselves 
to  the  position  of  lying  on  the  back  which  its 
use  necessitates.  It  is  no  kindness  to  allow 
a  child  to  further  irritate  the  already  badly 
involved  surfaces. 


FIG.    l6.       MASK    PATTERN 

The  mask. — In  facial  eczema,  the  itching  is 
often  most  intense.  In  order  to  effect  a  cure, 
scratching  and  rubbing  of  the  parts  on  any 
object  with  which  the  child  may  come  in  con- 
tact, must  be  prevented.  The  Thomas  mask 
(see  Fig.  16)  answers  this  purpose  admirably. 
The  ointment  or  lotion  is  placed  on  clean  linen 


Eczema  227 

which  rests  on  the  involved  parts.  Over  this 
is  placed  the  mask.  In  Fig.  16  is  represented 
a  pattern  of  the  mask.  Opening  A  is  suffi- 


FIG.    17.      MASK   IN   POSITION 

ciently  large  to  furnish  space  for  the  eyes,  nose, 
and  mouth.  An  elastic  band  which  will  be  seen 
to  pass  over  the  upper  lip,  draws  the  sides  of 
the  opening  together,  insuring  protection  to 
the  cheeks,  usually  the  parts  chiefly  involved. 
B  and  C  pass  over  the  top  of  the  head  and  are 
sewed  to  D  and  E  which  pass  over  the  ears,  to 


228  Hives 

the  back  of  the  head  where  they  are  united. 
The  masks  are  best  made  of  muslin  or  thin  old 
linen,  and  are  to  be  renewed  daily.  In  using 
an  ointment  under  the  mask  it  is  important 
that  it  be  spread  on  old  linen,  and  applied  to 
the  parts,  and  then  the  mask  placed  in  position 
holds  the  dressing  in  place. 

HIVES 

The  type  of  hives  most  frequently  seen  in 
children  appears  in  the  form  of  large  wheals 
from  one-half  to  one  inch  in  diameter.  There 
may  be  but  two  or  three  of  these  wheals,  or 
a  large  portion  of  the  body  may  be  covered  by 
them.  They  consist  of  a  firm,  flat,  circum- 
scribed, reddened  eruption  of  the  skin,  with- 
out any  definite  arrangement.  In  addition  to 
the  skin,  the  mucous  membrane  of  the  tongue, 
mouth,  and  pharynx  may  be  involved.  In 
some  instances  the  eruption  appears  very  sud- 
denly, lasts  but  a  few  hours,  and  quickly  dis- 
appears. If  the  attack  is  of  a  severe  nature 
new  spots  appear  from  time  to  time  which  be- 
have in  the  same  way.  Hives  in  children  are 
due  to  digestive  disorders.  I  have  repeatedly 
known  attacks  to  follow  some  unsuitable  arti- 


Milk-Crust  229 

cle  of  diet,  such  as  cakes,  strawberries,  pastry, 
or  nuts.  Constipation  may  cause  an  attack  or 
they  may  be  a  reaction  against  a  drug  or  some 
food  protein. 

The  only  symptom  of  consequence  is  the 
distressing  itching  which  is  always  present. 

Management.  —  Treatment  consists  in  the 
use  of  laxatives  and  a  temporarily  restricted 
diet.  The  itching  is  best  relieved  by  bathing 
the  parts  with  a  solution  of  carbolic  acid — one 
teaspoonful  to  a  pint  of  water. 

MILK-CRUST 

What  is  commonly  known  as  milk-crust 
consists  of  the  formation  on  the  scalp  of  a 
thick  layer  of  yellow  sebaceous  material. 
In  addition  to  being  unsightly  it  is  very  an- 
noying to  the  patient  on  account  of  the  itching 
which  it  causes.  The  mother  usually  assures 
us  that  the  condition  is  not  due  to  neglect.  The 
head  is  washed  and  oiled  very  often;  but  wash- 
ing will  neither  cure  nor  prevent  the  'disease. 

Milk-crust  is  due  to  an  inflammation  of  the 
sebaceous  glands  of  the  skin. 

Management. — The  affection  is  easily  ic- 
lieved.  The  hair  must  be  cut  very  short,  and 


230  Intertrigo 

an  ointment,  composed  of  resorcin,  twenty 
grains,  and  vaseline,  two  ounces,  should  be 
spread  generously  over  the  diseased  area  and 
covered  with  a  piece  of  linen  which  has  been 
saturated  with  the  ointment.  Over  this  a  fairly 
tight-fitting,  home-made  muslin  cap  should  be 
worn  to  hold  the  dressing  in  place.  The  oint- 
ment should  be  applied  twice  daily.  After 
three  or  four  days  of  the  treatment,  during 
which  time  no  water  must  touch  the  scalp,  it 
may  be  gently  cleansed  with  Castile  soap  and 
warm  water,  or  with  warm  sweet  oil. 

The  whole  or  the  greater  portion  of  the 
crusts  may  be  removed  with  the  first  washing. 
Some  severe  cases  may  require  two  or  three 
repetitions  of  the  treatment.  After  the  scalp 
is  clean,  an  application  of  the  ointment  at  bed- 
time once  or  twice  a  week  will  prevent  a  re- 
turn of  the  trouble. 

INTERTRIGO 

Inflammation  of  the  skin  of  the  thighs  and 
buttocks,  by  some  mothers  erroneously  called 
sprue,  is  often  seen  in  quite  young  children. 
If  the  child  is  allowed  to  lie  in  soiled  napkins, 
the  irritant  discharges  thus  remaining  in  con- 


Intertrigo  231 

\ 

tact  with  the  delicate  skin,  and  inflammation 
and  excoriation  of  the  parts  naturally  follow. 
Children  have  delicate  skins  and  often  pass  very 
acid  urine.  When  this  combination  is  present 
an  inflammatory  condition  of  the  parts  is  fre- 
quently difficult  to  avoid. 

Management. — The  management  is  simple, 
usually  requiring  only  a  changing  of  the  nap- 
kin as  soon  as  soiled  and  the  generous  use  of 
zinc  ointment.  I  have  had  very  little  success 
with  dusting  powders  in  such  cases,  especially 
in  those  of  any  degree  of  severity.  After  pas- 
sage either  from  the  bladder  or  bowels,  the 
napkin  should  be  immediately  removed,  the 
parts  gently  washed  with  Castile  soap  and 
boiled  water,  or,  in  some  cases,  warm  sterilized 
sweet  oil  may  be  used  to  better  advantage. 
After  the  parts  are  clean,  apply  to  the  inflamed 
area  pieces  of  clean  old  linen  which  have  been 
covered  with  zinc  ointment.  If  the  ointment 
is  applied  directly  to  the  skin  the  napkin  soon 
absorbs  it,  and  its  application  will  be  of  no 
service.  The  ointment  acts  as  a  barrier  be- 
tween the  irritating  passages  and  the  inflamed 
skin.  The  beneficial  effects  of  the  zinc  oint- 
ment will  be  appreciably  increased  if  white 
wax  (10%)  is  added  to  it.  Under  this  treat- 


232  Prickly  Heat 

ment  I  have  repeatedly  seen  the  worst  cases  of 
intertrigo  recover  in  a  week. 

Of  course  the  applications  must  be  repeated 
after  each  cleansing  and  drying.  The  oint- 
ment must  be  used  extravagantly.  The  dress- 
ing is  then  applied  to  the  parts  and  is  to  be 
changed  several  times  daily.  The  urine  which 
is  chiefly  at  fault,  is  prevented  by  the  ointment 
dressings  from  coming  in  contact  with  the 
skin,  the  treatment  being  solely  protective.  At 
the  same  time  a  quantity  of  absorbent  cotton 
is  placed  next  to  the  genitals  so  as  to  absorb 
the  urine  as  it  is  passed  and  thus  prevent  its 
general  distribution  over  the  parts.  When  the 
case  is  well  advanced  toward  recovery,  scrupu- 
lous cleanliness  and  a  dusting-powder  com- 
posed of  equal  parts  of  powdered  starch  and 
oxide  of  zinc  will  usually  be  all  that  is  required. 
In  all  children  or  when  there  is  an  inflamed 
condition  of  the  groins  and  buttocks  it  is  ad- 
visable to  put  on  the  napkins  in  rectangular 
form  as  described  on  page  4. 

PRICKLY  HEAT 

In  prickly  heat  there  is  an  acute  engorge- 
ment of  the  vessels  of  the  sweat-glands  with 


Prickly  Heat  233 

i 

obstruction  to  their  outlet.  Minute  papules 
form  which  are  reddish  in  color.  The  mild 
cases  are  without  inflammation.  When  in- 
flammation develops,  small  vesicles  also  ap- 
pear and  may  cover  large  areas  of  the  body. 
Nearly  every  infant  suffers  from  prickly  heat 
in  summer.  It  is  most  frequently  seen  on 
the  head  and  neck  and  over  the  chest  and 
shoulders.  The  patients  are  very  uncomfort- 
able and  restless.  There  is  evidently  a  great 
deal  of  burning  and  itching.  The  condition 
is  caused  by  heat,  due  either  to  too  much 
clothing  or  to  the  hot  weather  of  summer; 
both  causes  may  be  operative.  I  have  fre- 
quently seen  it  in  winter  in  overclad  children. 
Most  babies  are  overclad  at  all  seasons  of  the 
year.  When  prickly  heat  develops,  regardless 
of  the  season,  it  is  a  sure  sign  that  the  child 
has  been  kept  too  warm.  The  duration  is  de- 
pendent upon  climatic  conditions  and  also  upon 
the  treatment. 

Management. — Heavy  clothing  and  flannels 
are  to  be  avoided.  The  clothing  should  be 
light  in  weight  and  of  loose  texture.  In  order 
to  lessen  the  local  irritation  the  garment  worn 
next  to  the  skin  may  be  lined  with  silk,  linen, 
or  gauze.  The  further  means  of  management 


234  Prickly  Heat 

as  regards  both  the  relief  afforded  the  patient 
and  the  cure  of  the  condition,  consists  in  the 
frequent  application  of  cool  water,  in  the  form 
of  either  a  tub-bath  or  sponging.  The  soda 
bath,  the  bran  bath,  and  the  starch  bath  (page 
116)  are  all  most  useful.  For  purposes  of 
sponging,  a  solution  of  bicarbonate  of  soda 
should  be  used — one  tablespoon ful  to  a  gallon 
of  water.  The  relief  afforded  the  patient  de- 
pends not  so  much  upon  what  is  used  in  the 
water  as  upon  the  fact  that  plenty  of  cool  water 
comes  in  contact  with  the  itching,  burning 
skin.  Ointments  and  salves  are  of  little  service 
here,  as  they  tend  to  produce  further  macera- 
tion of  the  skin.  As  local  applications,  powders 
are  preferred  to  lotions.  A  powder  used  with 
satisfaction  in  this  condition  is  of  the  follow- 
ing composition : 

J$      Boracic  acid,  60  grains. 

Powdered  starch,  , 

each  i  ounce. 
Powdered  oxide  of  zinc, 


This  is  to  be  dusted  freely  over  the  involved 
surface  several  times  daily,  every  hour  if  neces- 
sary. 


Fissures  of  the  Anus      235 

FISSURES  OF  THE  ANUS 

In  children  suffering  from  what  are  called 
fissures  of  the  anus  there  will  be  found  one 
or  more  slight  tears  in  the  mucous  membrane 
just  inside  the  anal  aperture.  In  such  cases 
there  is  always  a  history  of  an  intestinal  dis- 
order, usually  constipation,  sometimes  diar- 
rhoea, the  fissures  having  been  caused 
either  by  a  stretching  of  the  parts  by  a  hard, 
constipated  movement,  or  by  the  frequent  irri- 
tant passages  which  have  caused  a  destruction 
of  the  mucous  membrane  of  the  parts. 

An  infant  thus  affected  cries  lustily  when 
having  a  passage,  and  strains  and  presses  for 
some  time  afterward.  Very  often  the  passage 
will  be  streaked  with  blood.  Older  children 
postpone  going  to  stool  as  long  as  possible  and 
complain  greatly  of  pain  when  the  bowels 
move. 

Management. — These  cases  will  be  greatly 
relieved  by  the  correction  of  the  intestinal 
derangement.  If  the  child  is  constipated,  the 
movements  should  be  kept  soft  by  the  use  of 
suitable  diet  and  laxatives.  (See  page  265.)  If 
there  is  diarrhoea,  suitable  diet  and  medical 
attention  are  necessary.  The  local  treatment, 


236  Boils 


which  may  be  necessary,  should  be  carried  out 
by  a  physician. 


BOILS 

Infants  are  particularly  subject  to  boils, 
which  are  supposed  by  many  to  indicate  some 
radical  blood  disorder.  As  a  result,  the  victims 
are  drugged  and  purged  with  all  sorts  of  teas 
and  "blood-purifiers."  The  cause  of  the  boil 
is  very  rarely  from  within.  It  is  usually  the 
result  of  a  local  infection  or  inoculation  into 
the  skin,  the  germs  finding  entrance  by  means 
of  a  hair  follicle  or  an  abrasion  so  small  as  to 
be  invisible  to  the  naked  eye.  A  boil  having 
formed,  the  pus  is  carried  to  other  portions  of 
the  skin  by  the  lymphatics,  or  it  escapes  upon 
the  surface,  and,  in  either  case,  other  portions 
of  the  skin  are  inoculated,  and  a  series  of  boils 
results.  The  parts  most  often  involved  are  the 
head,  the  neck,  and  the  shoulders,  although 
they  may  appear  upon  any  portion  of  the  body, 
with  the  exception  of  the  palms  of  the  hands 
and  the  soles  of  the  feet.  I  have  opened  one 
hundred  and  four  on  one  child  during  a  period 
of  three  weeks.  While  boils  are  more  fre- 
quently met  with  among  the  debilitated  and 


Head  Lice— Pediculi  Capitis  237 

weakly,  they  are  by  no  means  uncommon  in  the 
strong  and  otherwise  well. 

Management. — Poulticing,  and  allowing  a 
boil  to  open  spontaneously,  is  calculated  to  pro- 
long the  trouble  indefinitely.  A  boil  should 
be  opened  early,  the  pus  evacuated,  and  the 
surrounding  skin  thoroughly  washed  with  soap 
and  water,  when  an  antiseptic  dressing  com- 
posed of  several  thicknesses  of  old  linen,  which 
has  been  boiled  and  dried  and  then  dipped  into 
a  saturated  solution  of  boracic  acid,  answers 
every  purpose.  Not  only  the  boil  but  the  ad- 
jacent skin  for  several  inches  must  be  covered 
by  the  dressing,  which  is  to  be  kept  wet  with 
the  boracic  acid  solution. 

HEAD  LICE— PEDICULI   CAPITIS 

"«s 

Head  lice,  or  pediculi  capitis,  are  very  fre- 
quently seen  in  out-patient  and  hospital  work 
among  children  in  all  the  larger  cities.  Occa- 
sionally other  children  become  infected  in 
school  or  in  public  conveyances  and  carry  the 
vermin  to  other  members  of  the  family. 

Management. — The  most  successful  and 
cleanly  treatment  consists  in  cutting  the  hair 
short;  this  done,  wash  the  head  with  soap  and 


238  Fever 

water  once  a  day,  and  after  drying  moisten 
the  scalp  thoroughly  with  the  following  solu- 
tion twice  daily: 

Acetic  acid 2  drachms. 

Sulphuric  ether 3  ounces. 

Tincture  of  larkspur,   )      .       , 

~  .  .          .  .  )-  of  each  4  ounces. 

Spintus  vim  rect.,         j 

Improvement  will  follow  a  few  treatments. 
The  pediculi  will  be  killed  and  the  nits  may 
be  removed  with  a  fine-tooth  comb.  If  the 
patient  is  a  girl,  it  is  not  absolutely  necessary 
to  sacrifice  the  hair.  It  may  be  parted  from 
various  portions  of  the  scalp  and  the  solution 
applied  without  previous  washing.  However, 
if  the  hair  is  not  cut,  a  much  longer  time  will 
be  required  to  effect  a  cure. 

FEVER 

By  fever  we  understand  an  elevation  of  the 
temperature  of  the  body  above  the  normal, 
which  in  an  infant  is  99°  F.  by  rectum.  Fever, 
however,  does  not  constitute  disease.  It  is 
nothing  more  or  less  than  a  symptom,  but  it 
always  means  that  something  is  wrong  with 
the  baby.  It  may  be  due  to  a  slight  attack  of 


Fever  239 

indigestion,  the  eruption  of  teeth,  or  to  the 
beginning  of  scarlet  fever,  diphtheria,  or  some 
other  disease.  Children  develop  fever  much 
more  readily  than  adults,  and  it  is  of  less  signif- 
icance in  them.  A  child  with  fever  that  is 
appreciable  to  the  touch  of  the  mother  will 
usually  register  a  temperature  of  ioo.5°-ioi.5° 
F.  While  such  a  temperature  is  by  no  means 
alarming,  its  cause  should  be  discovered.  In 
the  absence  of  a  clinical  thermometer,  in  order 
to  examine  a  baby  for  fever,  place  upon  the 
abdomen  the  palm  of  a  hand  which  has  been 
previously  warmed.  Examination  of  a  child's 
hands,  head,  and  feet  furnishes  us  very  in- 
exact means  of  judging  as  to  the  question  of 
fever.  Many  times  these  parts  will  be  cold 
when  the  thermometer  registers  a  temperature 
of  104°  or  105°  F.  Every  young  mother 
should  possess,  and  know  how  to  use,  a  clinical 
thermometer. 

Management. — In  case  of  sudden  high 
fever — 104°  to  105°  F. — from  any  cause,  the 
mother  cannot  make  a  mistake  in  giving  an 
alcohol  and  water  sponge-bath  at  a  tempera- 
ture of  85°  F.  One  part  of  alcohol  may  be 
added  to  3  parts  of  water  and  the  child  sponged 
for  twenty  minutes.  If  necessary  the  sponging 


240  Malaria 

may  be  repeated  every  two  or  three  hours ;  this 
will  keep  the  child  comfortable  until  the  arrival 
of  the  physician  and  perhaps  prevent  unpleas- 
ant complications.  In  case  of  fever  the  nour- 
ishment should  always  be  reduced  at  once;  if 
the  child  is  on  the  bottle,  reduce  the  strength 
of  the  food  one-half  by  the  addition  of  boiled 
water.  If  the  child  is  nursed,  reduce  the  dura- 
tion of  each  nursing  period  one-third.  Chil- 
dren with  fever  can  always  have  plenty  of  cool 
boiled  water  to  drink.  Mothers  must  remem- 
ber that  it  is  not  the  fever  per  se,  but  the  con- 
dition of  the  patient,  which  governs  us  in  our 
treatment.  In  scarlet  fever  and  pneumonia,  a 
temperature  of  102°  to  104°  F.  is  expected,  and 
need  cause  no  alarm. 

MALARIA 

Children  in  New  York  City  and  vicinity 
occasionally  suffer  from  malarial  fever.  Fewer 
cases  come  under  my  observation  now  than 
formerly.  Malaria  is  caused  by  a  germ,  the 
Plasmodium  malaria. 

The  disease  is  transmitted  by  means  of  a 
mosquito.  The  mosquito  bites  an  individual 
who  has  malaria.  The  mosquito  becomes  in- 
fected and  infects  the  next  person  bitten. 


Tuberculosis  241 

The  fever,  languor,  and  drowsiness  will  ap- 
pear at  a  definite  time  each  day, — usually  from 
three  to  five  o'clock  in  the  afternoon.  The 
child  wakes  the  following  morning  apparently 
well,  but  at  about  the  same  hour  in  the  after- 
noon the  symptoms  are  repeated.  There  is 
always  a  distinct  periodicity  in  the  symptoms. 
In  some  cases  the  child  will  be  ill  every  second 
day,  but  at  the  same  hour.  In  other  cases  the 
symptoms  are  still  more  characteristic  and  are 
easily  recognized.  At  a  certain  time  every 
day,  or  perhaps  every  second  or  third  day, 
there  will  be  a  chill  and  a  rapid  rise  in  tempera- 
ture, followed  by  a  profuse  perspiration,  dur- 
ing which  the  fever  subsides. 

Management.  —  The  treatment  of  malaria 
4n  children  is  by  the  use  of  quinine.  The  ma- 
jority of  the  cases  recover  satisfactorily  under 
quinine,  but  it  should  never  be  given  without 
a  physician's  order. 

TUBERCULOSIS 

Tuberculosis  is  an  infectious  disease  which 
carries  off  one-seventh  of  the  population  of 
the  earth.  Children  are  very  susceptible  to  the 
infection.  The  disease  is  caused  by  the  en- 
trance into  the  system  of  a  micro-organism 

16 


242  Tuberculosis 

known  as  the  tubercle  bacillus.  Tuberculosis  is 
not  inherited.  The  disease  always  comes  from 
without,  as  does  typhoid  fever  or  diphtheria. 
We  often  see  parents  and  children  in  turn 
sicken  and  die  with  this  disease.  This  does 
not  necessarily  mean  heredity,  however.  It 
means  that  there  is  a  family  condition  of  con- 
stitution which  furnishes  a  favorable  soil  for 
the  development  of  the  bacillus.  If  all  who  swal- 
lowed or  inhaled  the  tubercle  bacillus  became 
tubercular,  the  earth  would  be  depopulated  in 
a  very  few  years.  We  have  all  taken  the 
tubercle  bacillus  into  our  bodies  at  some  time, 
probably  many  times.  In  one  individual  the 
germ  finds  a  favorable  soil  and  flourishes; 
in  another,  unfavorable  conditions — health  and 
vigor  of  constitution, — and  it  dies.  The  usual 
means  of  infection  is  through  the  inspired  air 
by  the  inhalation  of  the  infected  dust  from  the 
public  conveyances,  from  the  street,  or  from 
infected  dwellings,  or  in  association  with  peo- 
ple who  have  tuberculosis.  Children  being  very 
susceptible,  should  never  associate  with  tuber- 
cular adults.  Infection  may  also  take  place 
by  direct  contact  through  kissing.  The  bacillus 
may  be  swallowed  with  food  or  drink  which 
has  been  contaminated. 


Tuberculosis  243 

Parts  of  the  body  involved. — Almost  every 
portion  of  the  body  may  become  the  seat  of 
the  tubercular  process.  When  the  micro- 
organism attacks  the  lungs,  it  produces  what 
is  known  as  consumption,  or  pulmonary  tuber- 
culosis. When  the  covering  of  the  brain  is 
involved,  the  child  has  tubercular  meningitis. 
When  the  hip-joint  is  attacked,  hip-disease  fol- 
lows. When  the  spine  is  attacked,  it  produces 
what  is  known  as  Pott's  disease.  When  the 
glands  of  the  neck  are  infected,  scrofulous 
glands  or  tubercular  adenitis  is  the  outcome. 
Tubercular  disease  of  the  knee  is  commonly 
known  as  white  swelling.  These  are  the  parts 
which  are  most  frequently  the  seat  of  the 
tubercular  process.  With  less  frequency  the 
bacillus  attacks  the  bladder,  the  kidneys,  the 
skin,  the  intestines,  the  mesenteric  glands,  and 
the  peritoneum. 

General  tuberculosis. — In  institutions  and 
among  the  poor,  what  is  known  as  general 
tuberculosis  causes  the  death  of  many  infants. 
At  autopsy  they  show  an  involvement  of  nearly 
all  the  internal  organs.  Tuberculosis  in  chil- 
dren is  always  a  very  serious  disease,  but  it  is 
not  necessarily  fatal;  many  cases  recover. 
When  the  disease  involves  the  spine,  hip- joint, 


244  Rickets 

or  knee-joint,  or  the  glands  of  the  neck,  the 
prognosis  as  regards  life  is  usually  good.  When 
the  brain  is  attacked,  it  is  always  fatal.  In 
tubercular  disease  of  the  lungs  in  very  young 
children  the  prognosis  is  very  grave.  Many 
older  children — those  from  seven  to  twelve 
years  of  age — recover  if  the  disease  has  not 
progressed  too  far  before  coming  under  treat- 
ment. 

Management. — The  important  features  in 
the  management  of  these  cases  are :  competent 
medical  care,  change  to  a  dry  climate  at  an  ele- 
vation of  one  thousand  to  fifteen  hundred  feet, 
with  close  attention  to  hygiene  and  a  carefully 
regulated  diet  in  which  there  should  be  a  gener- 
ous allowance  of  meat,  eggs,  and  milk. 

RICKETS 

Rickets  is  a  constitutional  disease  due  to 
malnutrition.  The  lack  of  suitable  nourish- 
ment manifests  itself  in  characteristic  changes 
in  the  bones,  muscles,  and  in  the  nervous  sys- 
tem. In  addition  to  their  physical  characteris- 
tics, children  with  this  disease  may  show  de- 
layed mental  development.  A  rachitic  child 
is  usually  under  weight  and  undersized,  par- 


Rickets  245 

ticularly  as  regards  length.  The  head  is  ill- 
shaped,  the  enlargement  of  certain  bones  of  the 
skull  giving  the  head  a  square  appearance.  The 
sutures  and  fontanelle  close  very  late.  I  have 
seen  the  fontanelle  still  open  at  the  fourth  year. 
The  teeth  are  cut  late,  are  apt  to  be  soft,  and 
decay  early.  Many  rachitic  children  do  not 
get  the  first  teeth  until  after  the  twelfth  month 
is  passed.  The  chest  is  narrow  and  depressed 
at  the  sides,  and  along  its  anterior  portion,  at 
the  junction  of  the  costal  cartilages  with  the 
ribs,  a  row  of  nodules  can  be  traced.  The  ends 
of  the  long  bones,  particularly  at  the  wrists 
and  ankles,  are  very  much  enlarged.  In  many 
cases  this  enlargement  is  so  great  that  it  pro- 
duces quite  a  deformity.  Often  the  legs  are 
curved,  a  condition  known  as  "bow-legs."  The 
spine  is  weak  and  in  severe  cases  the  child  is 
unable  to  sit  erect.  Spinal  curvature  is  fre- 
quently seen  in  these  children.  The  abdomen 
is  usually  very  prominent.  The  malnutrition 
is  further  shown  by  the  flabby,  poorly  devel- 
oped muscles,  by  the  tendency  to  perspiration, 
particularly  about  the  head,  and  by  the  unstable 
nervous  system.  These  children  are  restless, 
irritable,  and  hard  to  please,  and  have  convul- 
sions under  slight  provocation.  Not  all  rachi- 


246  Scurvy 

tic  children  are  below  weight;  some  are  quite 
fat,  but  pale  and  flabby.  The  changes  in  the 
bones,  however,  are  similar  in  both  types.  In 
addition  to  the  characteristics  noted,  rachitic 
children  possess  feeble  powers  of  resistance. 
They  are  prone  to  catarrhal  affections  of  the 
respiratory  and  intestinal  tracts.  In  many  in- 
stances, they  teeth  late  and  with  much  diffi- 
culty. On  account  of  their  enfeebled  condition 
and  lack  of  resistance,  illness  in  a  rachitic  child 
is  apt  to  be  tedious,  if  not  serious. 

The  prevention  of  rickets  depends  upon 
'proper  feeding.  Condensed  milk  used  unad- 
visedly and  the  proprietary  meal  foods  are  re- 
sponsible for  many  cases. 

Management. — Proper  management  requires 
suitable  food,  cleanliness,  fresh  air,  and  cod- 
liver  oil.  By  "suitable  food"  is  meant  good 
milk  for  children  under  one  year,  to  which 
meat,  eggs  and  vegetables  are  added  as  soon 
as  they  can  be  digested — usually  after  the 
eighth  montn. 

SCURVY 

Scurvy  is  a  disease  of  quite  frequent  occur- 
rence among  bottle-fed  children.  It  is  charac- 


Scurvy  247 

terized  by  pain  in  one  or  more  of  the  joints  of 
the  long  bones,  with  or  without  swelling  of 
the  involved  parts  and  discolored,  spongy,  or 
bleeding  gums.  Hemorrhages  into  the  skin 
sometimes  occur,  which  give  the  child  a  pecul- 
iar mottled  appearance.  The  disease  is  often 
mistaken  for  rheumatism  because  of  the 
swollen  and  painful  joints.  If  the  case  is  a 
very  severe  one  it  may  resemble  paralysis  in 
some  of  its  aspects. 

The '  disease  is  due  to  errors  in  nutrition. 
The  great  majority  of  the  cases  develop  in 
those  who  are  being  fed  on  proprietary  meal 
foods,  condensed  milk,  and  overcooked  cows' 
milk. 

Among  the  author's  cases,  one  symptom 
was  always  present :  they  all  showed  evidences 
of  faulty  nutrition;  they  also  presented  another 
symptom  in  common  which  was  the  earliest 
active  manifestation  of  the  disease,  and  that 
was  pain.  The  child  that  has  been  playful, 
active,  and  has  enjoyed  attention,  suddenly 
undergoes  a  change — he  prefers  to  rest  in  the 
crib  or  carriage,  cries  when  handled,  and  re- 
fuses to  play.  Often  the  first  signs  of  trouble 
will  be  noticed  when  changing  the  napkin  or 
putting  on  the  shoes  or  stockings.  The  move- 


248  Scurvy 

ment  of  the  diseased  parts  causes  pain  and 
the  child  cries  lustily.  If  he  is  undressed  and 
rests  on  his  back,  the  affected  limb  in  all  proba- 
bility will  remain  motionless,  while  its  com- 
panion may  be  moved  freely. 

The  symptom  of  pain  appears  before  the 
swelling  of  the  joints,  which  is  sure  to  follow 
in  case  the  disease  is  not  recognized  early  and 
treated  properly.  Another  characteristic  symp- 
tom is  the  swollen,  congested,  and  bleeding 
gums  about  the  upper  incisor  teeth.  This  con- 
dition is  sometimes  seen  early  in  the  attack, 
but  it  is  usually  a  later  symptom.  Hemor- 
rhages into  the  skin  are  of  comparatively  in- 
frequent occurrence. 

Scurvy  uncomplicated  is  not  accompanied 
by  fever.  Acute  articular  rheumatism  is  always 
accompanied  by  fever.  Rheumatism  is  rare 
in  children  under  two  years  of  age;  scurvy  is 
rare  in  children  over  two  years  of  age.  There 
is  no  excuse  for  an  error  in  diagnosis  between 
the  two  affections. 

Management. — The  treatment  is :  fresh 
cows'  milk,  beef  juice,  and  orange  juice.  For 
a  child  one  year  of  age  the  juice  of  one  orange 
should  be  given  daily.  Under  proper  treat- 
ment the  average  case  will  be  well  in  a  week  or 


Rhuematism  249 

ten  days,  improvement  being  noticed  in  from 
twenty-four  to  forty-eight  hours  after  begin- 
ning the  treatment. 

RHEUMATISM 

Rheumatism  is  a  disease  of  very  grave  im- 
port and  of  rather  frequent  occurrence  among 
children  after  the  third  year.  Under  the  second 
year  it  is  of  the  rarest  occurrence.  At  this 
age  scurvy  is  frequently  diagnosed  as  rheuma- 
tism. It  may  appear  in  all  degrees  of  severity. 
The  mild  attacks  are  often  so  slight  that  a 
physician  is  not  consulted  and  the  diagnosis  of 
rheumatism  never  made.  Such  cases  are  often 
mistaken  for  sprains  and  so-called  "growing- 
pains."  Aside  from  this  mild  type  we  have  the 
disease  in  all  degrees  of  severity.  The  severe 
articular  form  known  as  inflammatory  rheu- 
matism, is  that  in  which  the  child,  with  high 
fever,  reddened,  swollen  joints,  dreads  your 
approach  to  the  bedside  and  begs  you  not  to 
touch  him. 

The  heart  in  rheumatism. — There  can  be  no 
attack  of  rheumatism  so  mild  that  it  should  be 
ignored.  Every  child  ill  with  this  disease  is 
in  danger  of  heart  complications  which  may 


250  Grippe 

make  him  an  invalid  for  life.  Probably  nine- 
tenths  of  the  cases  of  valvular  heart  disease  in 
adults  are  due  to  attacks  of  rheumatism  during 
childhood,  and  in  many  instances  the  disease 
of  the  heart  is  not  recognized  until  long  after 
the  rheumatic  attack.  In  every  case  of  rheu- 
matism the  heart  should  be  examined  and  prop- 
erly treated.  Heart  involvement  is  as  liable  to 
develop  in  the  mild  as  in  the  severe  attacks. 
In  some  cases  it  is  the  only  evidence  of  the 
presence  of  rheumatism.  Children  of  rheu- 
matic parentages  and  those  who  show  rheu- 
matic tendencies  should  be  under  the  constant 
supervision  of  a  physician. 

GRIPPE 

Grippe  is  a  disease  very  prevalent  among 
children  during  the  colder  months.  It  is  due 
to  a  micro-organism  which  is  usually  taken 
into  the  system  with  the  inspired  air.  There 
are  four  types  of  the  disease  to  be  seen  in  chil- 
dren. 

In  the  most  common  type  the  respiratory 
passages  are  the  parts  chiefly  involved.  The 
symptoms  resemble  in  some  respects  those  of 
a  common  cold.  There  is  running  at  the  nose, 


Grippe  251 

cough,  sore  throat,  and,  generally,  bronchiits. 
There  is  a  higher  fever,  however,  than  can  be 
explained  by  the  catarrhal  symptoms,  greater 
muscular  weakness,  and  greater  prostration. 
If  uncomplicated,  the  disease  usually  runs  its 
course  in  from  five  to  eight  days.  The  com- 
plications to  be  especially  dreaded  are  bronchi- 
tis, pneumonia,  and  otitis. 

The  next  most  frequent  type  of  grippe  is 
the  muscular.  There  is  fever,  headache,  loss 
of  appetite,  prostration,  and  great  muscular 
weakness.  There  is  little  or  no  involvement 
of  the  respiratory  tract. 

The  third  type  includes  the  cases  in  which 
the  intestinal  symptoms  predominate.  The 
child  is  taken  ill  suddenly  with  fever,  prostra- 
tion, and  diarrhoea  which  is  very  hard  to  con- 
trol. There  are  from  eight  to  sixteen  green, 
watery  passages  daily,  containing  a  moderate 
amount  of  mucus,  streaked  with  blood.  There 
is  also  slight  cough  and  coryza,  with  consider- 
able congestion  of  the  throat. 

In  the  fourth  type  the  nervous  system  is 
chiefly  affected.  These  patients  have  the  fever 
and  muscular  soreness  common  to  all  varieties, 
with  the  prominent  symptom — excessive  irri- 
tability. In  some  cases  there  seems  to  be  al- 


252  Grippe 

most  entire  loss  of  self-control.  The  patients 
are  peevish,  fretful,  depressed  and  hysterical 
by  turn.  They  cannot  bear  the  slightest 
noise,  and  sleep  only  when  under  the  influence 
of  drugs. 

The  severe  cases,  however,  have  two  symp- 
toms common  to  all — fever  and  intense  pros- 
tration; prostration  and  weakness  out  of 
proportion  to  all  objective  symptoms  are  the 
peculiar  characteristics  of  grippe.  I  have  lost 
two  patients  aged,  respectively,  three  and  four 
months,  in  both  of  which  the  system  was  com- 
pletely overwhelmed  by  the  virulence  of  the 
grippe  poison.  Both  children  died  in  less  than 
twenty-four  hours,  apparently  from  exhaus- 
tion. Post-mortem  examination  failed  to  de- 
tect in  either  case  any  organic  change  sufficient 
to  cause  death. 

A  very  unpleasant  feature  of  grippe  is  the 
wretched  physical  condition  in  which  the 
patient  is  often  left  after  the  acute  symptoms 
have  disappeared.  Weeks  of  the  most  careful 
treatment  will  frequently  be  required  to  re- 
store his  previous  good  health.  A  feature  in 
grippe  is  the  tendency  toward  a  slight  rise  of 
temperature  y2  to  i°  F.  after  the  child  is  other- 
wise well. 


Convulsions  253 

Management. — There  is  no  specific  treat- 
ment for  this  disease.  Every  case  must  be 
treated  according  to  the  symptoms  presented. 
For  those  which  fail  to  make  prompt  recovery 
a  change  of  climate  should  be  advised.  Many 
of  my  patients  have  done  surprisingly  well  at 
Lakewood,  or  at  Atlantic  City. 

CONVULSIONS 

A  convulsion  is  a  temporary  loss  of  con- 
sciousness, associated  with  rhythmical  con- 
tractions of  various  muscles  of  the  body. 
Rachitic,  delicate  children,  and  those  suffering 
from  malnutrition  in  any  form  are  predis- 
posed to  convulsions.  Disturbances  in  the 
gastro-intestinal  tract,  due  to  errors  in  feed- 
ing, have  been  the  cause  in  ninety-five  per  cent, 
of  my  cases.  Nearly  all  were  seen  among  the 
badly  bottle-fed  or  in  those  beyond  the  bottle 
age  who  had  been  given  food  unsuited  to  their 
years.  I  have  frequently  known  seizures  to 
follow  an  unusual  indulgence  in  cake,  pie,  or 
fruit.  Excessively  high  fever  may  be  a  cause 
of  convulsions.  Pneumonia,  meningitis,  and 
contagious  diseases  are  sometimes  ushered  in 
by  convulsions.  Heat  prostration  and  worms 


254  Convulsions 

may  be  mentioned  as  infrequent  causes.  A 
patient — a  boy  three  years  old — had  repeated 
convulsions  until  he  was  relieved  of  forty-three 
large  round  worms.  According  to  my  obser- 
vation, dentition  is  rarely  an  immediate  cause. 
The  dentition  period  covers  eighteen  months, 
and  children  often  have  convulsions  during 
this  time;  a  thorough  examination  of  the  pa- 
tient, however,  will  usually  reveal  the  seat  of 
the  trouble  in  the  intestinal  canal  or  stomach. 
Dentition  may  indirectly  be  a  factor.  A  few 
years  ago  a  mother  insisted  that  I  should  lance 
the  healthy  gums  of  a  girl  eighteen  months  of 
age,  who  repeatedly  had  convulsions.  This  I 
refused  to  do,  and  ordered,  instead,  two  tea- 
spoonfuls  of  castor-oil.  The  child  passed  one- 
quarter  of  a  partially  masticated  orange  and 
the  convulsions  ceased. 

Management. — When  a  child  is  attacked, 
prompt  action  is  necessary.  The  family  phy- 
sician should  be  sent  for  and  the  patient  placed 
at  once  in  a  mustard  bath  at  a  temperature  of 
105°  F. ;  an  even  tablespoonful  of  mustard 
should  be  added  to  five  gallons  of  water.  The 
patient  should  not  be  allowed  to  remain  in  the 
bath  over  ten  minutes,  when  he  should  be  re- 
moved and  dried  vigorously.  If  possible,  the 


Convulsions  255 

child's  temperature  should  be  taken  while  in 
the  bath,  and  if  above  102°  F.  (in  convulsions 
it  usually  ranges  between  104°  and  io6°F.) 
the  temperature  of  the  water  should  be  lowered 
to  75°  or  80°  F.  by  the  addition  of  ice  or  cold 
water.  Watch  the  effect  of  the  cooling  of  the 
bath  upon  the  child's  temperature,  and  when  it 
is  reduced  to  101°  F.  remove  him.  The  tem- 
perature in  convulsions  should  always  be  noted. 
To  my  mind  the  high  fever  has  oftentimes  a 
great  deal  to  do  with  the  seizure.  Not  long 
since  J^was  called  to  see  a  child  in  convulsions. 
Upon  my  arrival  I  learned  that  he  had  been 
put  into  a  hot  bath  at  110°  F.,  and  kept  there 
fifteen  minutes,  but  the  child  showed  no  signs 
of  improvement.  The  temperature  was  taken 
while  in  the  bath,  and  registered  ni°F.,  as 
high  as  the  thermometer  would  register.  In 
this  case  the  hot  bath  was  the  worst  means  of 
treatment  that  could  be  devised.  There  is  no 
advantage  in  making  the  water  hotter  than  105° 
F.  In  the  bath,  or  immediately  upon  removal, 
give  an  enema  of  soap  and  water  so  as  to  in- 
sure a  movement  of  the  bowels  as  soon  as  possi- 
ble. As  soon  as  the  child  can  swallow,  one  or 
two  teaspoonfuls  of  castor-oil  should  be  given. 
If  it  is  known  that  the  child  has  taken  some- 


256  Colic 

thing  indigestible,  a  teaspoonful  of  syrup  of 
ipecac  should  be  given,  and  repeated  in  twenty 
minutes  if  vomiting  does  not  follow.  The  con- 
vulsion is  very  apt  to  be  repeated  if  the  cause 
is  not  removed.  The  patient  should  not  be  held 
on  the  lap.  He  should  be  placed  in  his  crib 
and  kept  very  quiet.  Cold  cloths  should  be 
applied  to  the  head  and  a  hot-water  bag  to  the 
feet.  No  solid  food  or  milk  should  be  given 
for  twenty- four  hours;  broths  and  barley- 
water  should  constitute  the  diet.  During  the 
next  few  days  there  should  be  no  excitement,, 
and  the  physician's  orders  regarding  medica- 
tion and  diet  should  be  carefully  carried  out. 

COLIC 

There  are  few  children  who  reach  the  age 
of  one  year  without  having  suffered  from 
colic.  Infants  in  the  earliest  months  of  life- 
are  particularly  susceptible  to  such  attacks. 
The  majority  of  cases  are  seen  in  children: 
under  five  months  of  age,  although  the  seiz- 
ures may  continue  until  a  much  later  period. 
During  the  attack  the  child  cries  violently, 
becomes  red  in  the  face,  clinches  its  fists,  draws 
up  its  legs,  doubles  up  its  body,  and  straightens. 


Colic  257 

out  again.  The  abdomen  is  hard,  often  dis- 
tended, and  the  hands  and  feet  are  cold.  The 
child  rests  a  few  moments  and  cries  again. 
Often  all  attempts  at  comforting  him  fail. 
An  attack  may  continue  for  a  few  moments  to- 
an  hour  or  more,  perhaps  until  the  child  sleeps 
from  exhaustion.  I  have  had  children  brought 
to  me  for  treatment  who  were  so  hoarse  from 
crying  that  they  could  scarcely  utter  a  sound. 
There  may  be  several  attacks  a  day  after  the 
feedings  or  they  may  not  appear  until  evening. 
Afternoon  or  evening  colic  is  probably  most 
frequent.  These  cases  are  easily  explained.  The 
overtaxed  stomach  has  done  its  work  fairly 
well  early  in  the  day,  but  as  the  improper,  fre- 
quent feedings  follow,  it  becomes  tired  and 
refuses  to  work  "overtime."  During  the  night 
some  rest  is  obtained,  but  the  following  day 
the  entire  programme  is  repeated.  So-called 
colicky  children  are  often  otherwise  perfectly 
well.  If  the  trouble  is  not  particularly  severe, 
they  may  be  well-nourished  and  well-behaved 
babies  when  not  in  pain.  In  the  severe  cases 
there  is  apt  to  be  evidence  of  marked  malnu- 
trition. It  is  often  remarked  that  "a  baby 
must  do  just  so  much  crying,"  and  nothing 
is  done  to  relieve  it.  If  one  baby  cries  more 


258  Colic 

than  another  it  is  because  he  suffers  more.  A 
baby  rarely  cries  unless  he  is  uncomfortable 
or  in  pain.  He  may  cry  while  his  clothing  is 
being  changed  because  it  disturbs  him;  he  will 
cry  from  cold,  hunger,  from  the  effects  of  a 
misdirected  pin,  or  from  pain  of  any  nature, 
but  never  without  reason.  The  general  ten- 
dency of  the  child  is  to  play,  to  smile  and  be 
happy.  When  this  is  not  the  case  something 
is  wrong. 

Cause  of  colic. — Colic  in  every  instance 
means  indigestion.  It  means  that,  whether 
breast-fed  or  bottle-fed,  the  food  is  not  suit- 
able,— is  not  adapted  to  the  child's  digestive 
powers,  or  not  properly  given.  The  child  who 
suffers  from  habitual  colic  is  usually  consti- 
pated. It  has  been  my  experience  that  the 
chief  error  in  the  diet  causing  the  colic  was 
the  excess  of  the  proteid — the  curd-forming 
element  in  the  milk.  It  is  thus  practically  use- 
less to  give  carminatives  and  soothing  syrups, 
and  other  remedies  of  a  sedative  nature,  ex- 
cepting for  the  immediate  effects. 

General  management. — Whatever  error  may 
exist  in  the  feeding  must  be  corrected.  If  the 
patient  is  a  breast-baby  we  must  treat  the 
mother — the  source  of  the  child's  nourishment. 


Colic  259 

Nursing  mothers  of  colicky  babies  are  usually 
of  sedentary  habits,  hearty  eaters,  and  consti- 
pated. Our  first  step  must  be  to  cure  the  con- 
stipation of  the  mother.  She  should  have  one 
full,  free  passage  from  the  bowels  daily.  She 
should  exercise  in  moderation  in  the  open  air :  a 
walk  of  an  hour  or  two  in  the  morning,  and  an 
hour  in  the  afternoon,  will  be  most  beneficial. 
Her  diet  should  consist  of  fresh  meat,  poultry, 
fish,  cereals,  soups,  baked  potato,  green  vege- 
tables, and  stewed  fruit.  Coffee  may  be  taken 
in  moderation;  milk,  cocoa,  chocolate,  and 
water  may  be  taken  freely.  A  nursing  mother 
should  drink  no  tea.  It  is  a  popular  idea  that 
tea  is  a  very  necessary  article  for  the  nursing 
mother.  Hardly  a  week  passes  but  I  hear 
from  the  out-patient  mother  of  a  sick  breast- 
baby  that  she  is  drinking  from  one  to  two  gal- 
lons of  tea  a  day.  The  tea  is  kept  "on  the  back 
of  the  stove,"  so  as  to  be  ready  for  use  at  any 
time.  I  have  relieved  many  cases  of  colic  in 
the  child  simply  by  curing  the  mother's  con- 
stipation and  regulating  her  diet. 

Menstruation  often  causes  temporary  at- 
tacks of  colic  and  other  digestive  disturbances 
in  the  child.  Fright,  anger,  worry,  or  any- 
thing in  the  nature  of  a  shock  in  the  mother 


26o  Colic 

will  often  seriously  affect  the  child's  digestion. 
In  short,  when  the  nursing  child  suffers  thus 
from  digestive  derangements,  the  error,  nine 
times  out  of  ten,  rests  with  the  mother.  The 
trouble  is  rarely  with  the  child. 

As  previously  stated,  habitual  colic  in  the 
bottle-fed  tells  us  that  we  are  not  giving  the 
child  a  suitable  food,  or  that  we  are  not  giving 
a  suitable  food  properly.  The  food  as  a  whole 
may  be  too  strong  or  too  weak.  It  may  be 
given  too  frequently.  If  cows'  milk  is  the  diet, 
the  error  is  often  due  to  improper  modification. 
The  proteid  will  usually  be  found  in  excess,  not 
in  excess,  perhaps,  for  the  average  child,  but  in 
excess  for  the  patient  in  question.  There  can 
be  no  set  rules  for  feeding  or  definite  formulae 
for  various  ages  that  are  infallible.  The  food 
of  artificially  fed  children  must  be  adapted  to 
meet  their  individual  requirements.  The  treat- 
ment of  habitual  colic  in  the  bottle-fed  consists 
in  rendering  the  food  suitable. 

Management  of  acute  attacks. — For  the  re- 
lief of  immediate  attacks,  an  injection  of  from 
six  to  eight  ounces  of  water  at  no°F.,  to 
which  one-half  teaspoon ful  of  salt  has  been 
added,  will  often  be  of  service.  Five  to  eight 
drops  of  gin  in  a  teaspoonful  of  warm  water, 


Constipation  261 

by  mouth,  is  sometimes  useful.  Two-drop 
doses  of  Hoffmann's  Anodyne  in  two  teaspoon- 
fuls  of  hot  water  will  frequently  cut  short  a 
severe  attack.  Both  the  gin  and  the  anodyne 
may  be  repeated  in  one-half  hour  if  relief  is 
not  obtained.  If  the  attack  is  prolonged,  a  hot- 
water  bag  should  be  placed  at  the  feet,  and 
flannels  wrung  out  of  hot  water  applied  to  the 
abdomen.  Oftentimes,  in  order  that  the  diges- 
tive ojgans  may  have  a  complete  rest,  it  is  ad- 
visable to  discontinue  the  regular  food  for  a 
few  hours  and  give  barley-water  as  a  substi- 
tute. 

CONSTIPATION 

Among  the  derangements  of  the  young, 
there  are  few  which  give  more  annoyance  or 
are  harder  to  manage  successfully  than  con- 
stipulation.  The  causes  of  the  trouble  are  ana- 
tomical and  dietetic.  The  comparatively  long 
large  intestine  folded  upon  itself  in  the  nar- 
row pelvis  offers  an  obstruction  to  the  free 
passage  of  the  intestinal  contents.  The  lack 
of  development  of  the  muscular  structure  of 
the  intestine  is  also  a  cause.  Deficient  nerve 
power,  due  to  lack  of  development  of  the  sym- 


262  Constipation 

pathetic  nervous  system,  is  thought  by  many 
to  be  an  important  factor.  In  all  probability 
all  these  agents  may  be  regarded  as  predispos- 
ing causes  of  constipation.  The  chief  cause  of 
constipation,  however,  according  to  my  obser- 
vation, is  the  proteid  (the  curd)  in  the  child's 
milk.  When  the  amount  of  proteid  is  exces- 
sive— a  higher  percentage  than  normal — the 
child  is  apt  to  be  constipated.  A  child  fed  on 
a  normal  proteid  with  a  low  fat  may  also  be- 
come constipated. 

Management  in  the  breast-fed. — Among  the 
breast-fed,  the  dietetic  management  of  this 
disorder  is  difficult,  for  it  is  hard  to  change 
the  character  of  the  mother's  milk.  Much  may 
be  done,  however.  Inquiry  into  the  daily  life 
of  the  mother  will  usually  disclose  sedentary 
habits,  a  good  appetite,  a  fondness  for  tea, 
and,  probably,  constipation.  An  examination 
of  the  milk  of  these  mothers  will  show  that 
the  normal  proportions  of  fat,  proteid,  and 
sugar  are  not  maintained.  The  percentage  of 
proteid  is  usually  found  to  be  higher  than 
normal,  with  low  or  normal  fat. 

The  first  step  in  the  treatment  is  the  regu- 
lation of  the  habits  of  the  mother.  The  bowels 
should  be  evacuated  daily,  with  a  laxative,  if 


Constipation  263 

necessary.  She  should  be  placed  on  a  diet  of 
fresh  meat,  fresh  vegetables,  and  fruit.  A 
malt  liquor  with  luncheon  or  dinner  is  also 
sometimes  recommended.  She  is  instructed 
to  take  exercise  daily  in  the  open  air.  This 
regime  will  diminish  the  proteid  and  increase 
the  fat  in  her  milk,  and  not  only  relieve  con- 
stipation in  the  child,  but  insure  better  nourish- 
ment and  a  later  weaning  than  would  otherwise 
be  possible.  The  treatment  of  the  mother  is 
all  that  is  necessary  in  a  considerable  num- 
ber of  cases,  but  when  this  fails,  the  child  de- 
mands attention. 

In  treating  the  child  my  first  step  is  to  give 
cream ;  not  cream  purchased  as  such,  but  cream 
which  rises  upon  the  best  milk  obtainable.  I 
give  from  one-half  to  two  teaspoonfuls  in  quite 
warm  water  immediately  before  nursing.  The 
use  of  the  gluten  suppository  at  the  same  hour 
for  several  consecutive  days  will  do  much  to 
establish  the  habit  of  a  passage  at  a  regular 
hour  each  day. 

In  case  the  cream  does  not  agree  with  the 
child  or  is  ineffective,  pure  cod-liver  oil — 
fifteen  to  thirty  drops  three  or  four  times  a 
day,  or  one  teaspoonful  of  sweet  oil  two  or 
three  times  a  day — may  prove  beneficial. 


264  Constipation 

When  these  measures  fail,  as  they  will  in  a 
small  number  of  cases,  liquid  albolene  (aro- 
matic), so-called  mineral  oil,  may  be  used,  two 
to  four  teaspoonfuls  daily.  Whenever  medi- 
cation is  used  it  should  be  given  immediately 
before  the  meals.. 

In  all  my  breast-fed  babies  one  bottle 
feeding  daily  is  advised,  in  the  constipated 
infant  the  feeding  may  consist  of  malted 
milk  which  is  laxative  to  many  infants.  Five 
rounded  teaspoonfuls  are  added  to  six  ounces 
of  hot  water. 

Never  allow  a  baby  or  young  child 
to  be  put  to  bed  for  the  night  without  an 
evacuation  of  the  bowels  having  taken  place, 
during  the  previous  twenty- four  hours.  An 
enema  of  soap  water  four  to  eight  ounces,  or 
a  gluten  suppository  should  be  used  in  such  an 
emergency. 

Management  of  the  bottle-fed.  —  In  our 
treatment  of  infants  a  feature  not  to  be  lost 
sight  of  is  that  the  principle  business  of  the 
small  individual  is  to  grow  normally — not  only 
as  regards  weight  and  height,  but  he  is  re- 
quired to  develop — good  bone  and  muscle  and 
nerve  structure. 

In  order  for  this  to  take  place  he  must  have 


Constipation  265 

food  containing  certain  nutritious  elements. 
We  are  thus,  limited  in  our  dietetic  manage- 
ment because  considering  only  the  constipated 
infant  we  might  remove  certain  food  elements 
necessary  to  the  growth  of  the  child.  If  a 
child  is  thriving  on  the  bottle  formula  and  all 
is  well  excepting  the  constipation,  it  is  not 
wise  to  make  too  radical  changes.  The  only 
change  permissible  rests  with  the  sugar,  and 
all  sugars  have  practically  the  same  nutritional 
valued  Instead  of  using  milk  sugar  in  the 
formula,  we  would  suggest  a  formula  which 
has  laxative  variety,  such  as  the  sugar  we  have 
in  Dextra  Maltose  No.  Ill  to  be  used  in  the 
same  proportion  as  milk  sugar  or  Mellin's 
Food  which  is  a  Dextra  Maltose  and  may  be 
employed  in  similar  amounts.  The  milk  given 
the  bottle-fed  constipated  infant  should  not 
be  cooked  if  the  season  of  the  year  and  the 
character  of  the  milk  allows.  Neither  lime 
water  or  barley  should  be  used  in  the  formula. 
Oatmeal  may  be  substituted  for  barley  and  milk 
of  magnesia  one  to  three  teaspoonfuls  suffi- 
cient to  act  as  a  mild  laxative  may  be  used  in 
place  of  lime  water. 

Management  in   older   children. — In    "run- 
about" children  the  use  of  cream  and  water 


266  Constipation 

mixtures,  rare  meat,  green  vegetables,  stewed 
and  raw  fruit,  renders  the  management  of 
constipation  exceedingly  simple.  The  meals 
must  be  given  at  regular  intervals,  and  crackers 
and  white  bread  excluded.  The  Bennett's 
wheatsworth  biscuit  and  whole  wheaten  bread 
may  be  used  with  advantage.  One  tablespoon 
Kellogg's  bran  may  be  added  to  cereal  once 
or  twice  a  day.  Fruits  are  best  given  between 
meals.  The  juice  of  two  oranges  may  be  given 
at  9  A.M.,  or  four  ounces  of  prune  juice  and 
apples,  pears,  grapes,  or  peaches  at  4  P.M. 

It  is  our  hope  in  treating  constipation  to 
relieve  the  patient  by  the  dietetic  measures 
above  suggested.  When  these  fail,  we  must 
resort  to  other  means.  Enemas  and  supposi- 
tories may  be  used  occasionally,  but  the  child 
should  not  become  accustomed  to  them.  In 
the  severe  cases  which  resist  dietetic  treatment, 
the  outlook  for  an  early  recovery  is  not  promis- 
ing. In  such  cases  the  use  of  an  enema  of 
olive  oil  at  bedtime  has  proven  very  satisfac- 
tory. A  small  amount  of  the  oil,  two  to  three 
ounces,  is  introduced  through  a  large  catheter, 
No.  1 8  American  (male),  which  is  inserted 
ten  or  twelve  inches,  the  catheter  being  at- 
tached to  a  bulb  syringe  with  a  capacity  of 


Constipation  267- 

six  ounces  (see  Fig.  18).  An  evacuation  is 
not  desired  until  the  following  morning,  when 
the  child  is  placed  at  stool  after  his  breakfast 
and  allowed  to  remain  fifteen  minutes.  If  no 


FIG.    l8.      THE  BULB   SYRINGE 

evacuation  occurs  at  the  end  of  this  time,  a 
slight  stimulation  in  the  use  of  a  suppository 
or  soap-suds  may  be  used  to  bring  it  about. 
In  a  comparatively  few  days  usually  the  morn- 
ing evacuation  takes  place  without  assistance. 
The  oil  should  be  continued  for  several  days, 
when  it  may  be  omitted  one  night  in  seven. 
When  an  evacuation  follows  the  next  morning, 
it  may  be  omitted  one  night  in  five.  In  this 


268  Vaccination 

way  the  oil  may  be  gradually  lessened  until  it 
is  no  longer  required.  In  some  children  a  small 
amount  of  the  oil  will  be  passed  during  the 
night.  These  should  wear  a  napkin.  At  this 
age  also  the  liquid  albolene  (aromatic)  may 
be  used  in  dosage  of  one  to  two  tablespoonfuls 
at  bedtime. 

VACCINATION 

Every  baby  in  fair  health  should  be  vac- 
cinated not  later  than  the  third  month — before 
any  trouble  incident  to  dentition  may  arise; 
for  the  younger  the  child,  the  less  the  consti- 
tutional disturbance.  Vaccination  in  a  child 
two  to  three  months  of  age  causes  practically 
no  illness  whatever.  Both  sexes  should  be 
vaccinated  on  the  outer  side  of  the  calf  of  the 
leg:  girls,  because  the  resulting  scar  on  the 
arm  may  be  regarded,  in  later  life,  as  a  dis- 
figurement; and  both  boys  and  girls,  because 
when  the  sore  is  on  the  leg  it  is  more  easily 
cared  for.  In  dressing  and  undressing  a  child, 
the  arm  has  to  be  manipulated  to  a  considera- 
ble extent,  thus  causing  more  or  less  discom- 
fort. 

Management   of   the  wound. — The   wound 


Vaccination  269 

should  be  kept  covered  with  a  sterilized  gauze 
bandage  until  the  crust  falls,  leaving  the  dry 
pink  skin  underneath.  Tub  bathing  should  be 
discontinued  until  this  takes  place. 

Vaccination  shields  are  all  worse  than  use- 
less; they  are  often  positively  harmful,  for 
they  usually  become  displaced  and  may  irri- 
tate and  infect  the  sore.  When  unpleasant 
results  follow  the  vaccination,  the  virus  is 
rarely  at  fault.  The  infection  is  usually  due 
to  carelessness  or  to  uncleanliness  in  the  treat- 
ment of  the  wound. 

Necessity  of  vaccination. — Vaccination  will 
always  be  considered  by  people  who  enjoy  the 
possession  of  an  ordinary  amount  of  knowl- 
edge and  a  moderate  amount  of  common-sense 
as  one  of  the  greatest  discoveries  of  medical 
science.  Since  its  discovery  by  Jenner,  as 
statistics  show,  millions  of  lives  have  been 
saved  by  vaccination.  It  would  seem  strange 
that  one  should  feel  it  necessary  to  speak  in 
defence  of  a  measure  which  has  been  of  such 
incalculable  value  to  the  human  race,  but  there 
are  a  noisy  lot  of  mentally  incompetent  anti- 
vaccinationists,  who  are  not  without  influence 
among  their  kind  and  the  otherwise  ignorant, 
upon  whom  the  following  statistics  by  Allen 


270  Bed-Wetting 

(Pediatrics,  February,  1900)  would  produce 
no  effect : 

In  1871,  Germany  lost  one  hundred  and 
forty-three  thousand  lives  by  smallpox;  in 
1874,  a  law  was  enacted  making  vaccination 
obligatory  during  the  first  year  of  life  and 
compelling  its  repetition  during  the  tenth  year. 
The  result  was  that  the  disease  almost  entirely 
disappeared.  At  the  present  time  the  loss  of 
life  from  this  disease  throughout  the  empire 
is  scarcely  one  hundred  a  year.  At  the  time 
of  the  Franco-Prussian  War,  the  entire  Ger- 
man Army  was  re-vaccinated;  while  in  the 
French  Army,  vaccination  being  optional, 
comparatively  few  were  vaccinated.  Both 
armies  were  attacked  by  smallpox,  the  French 
losing  twenty-three  thousand  men,  the  Ger- 
man, two  hundred  and  seventy-eight.  With 
such  statistics  how  can  there  be  any  plausibility 
in  the  argument  of  the  anti-vaccinationists  ? 

BED-WETTING 

The  urine  is  voided  involuntarily  by  most 
children  until  well  into  the  second  year.  If 
the  child  is  carefully  trained,  the  function  of 
urination  may  be  under  perfect  control  dur- 
ing the  waking  hours  by  the  end  of  the  first 


Bed-Wetting  271 

year.  We  hear  now  and  then  of  a  child  who 
urinates  voluntarily  at  the  age  of  six  months. 
Such  children  are  rare.  The  urine  is  passed 
normally  during  sleep  until  the  child  is  two  and 
one-half  or  three  years  of  age.  In  many  this 
will  be  controlled  at  the  end  of  the  second  year, 
but  I  do  not  regard  the  lack  of  control  as  an 
abnormality  until  the  third  year  is  reached.  If 
the  urine  is  passed  involuntarily  after  the  child 
is  three  years  old,  a  physician  should  be  con- 
sulted, not  necessarily  to  give  drugs,  but  to 
instruct  the  mother  as  to  the  diet  and  general 
hygiene. 

Causes  of  bed-wetting. — Incontinence  of 
urine  may  be  due  to  a  great  variety  of  causes, 
among  which  may  be  mentioned  a  highly  acid 
urine,  stone  in  the  bladder,  which  is  of  com- 
paratively rare  occurrence,  adenoids,  thread- 
worms, constipation,  inflammation  of  the  vulva 
and  vagina  in  girls,  and  tightly  adherent  fore- 
skin in  boys.  By  far  the  greatest  number  of 
cases,  however,  are  due  to  a  lack  of  develop- 
ment of  the  nervous  system  and,  in  addition, 
a  bad  habit.  Not  infrequently  the  trouble  is 
caused  by  over  indulgence  in  water  and  milk 
late  in  the  afternoon  and  during  the  night.  It 
is  rarely  a  symptom  of  kidney  or  bladder  dis- 


272  Bed-Wetting 

ease.  The  relief  of  the  inveterate  bed-wetter 
of  five  or  six  years  of  age  is  often  most  diffi- 
cult. The  child  must  be  examined  by  a  physi- 
cian to  determine  that  there  is  no  local  cause 
for  the  trouble.  If  no  such  cause  is  found, 
well-directed  medication,  with  the  mother's  co- 
operation, will  usually  relieve  the  patient,  al- 
though it  may  require  months  to  do  it.  In 
the  cases  of  only  occasionally  bed-wetting,  and 
with  younger  patients,  the  mother  alone  can 
often  accomplish  considerable. 

Management. — No  water  or  milk  should 
be  given  after  four  o'clock  P.M.  The  child 
should  have  a  dry  supper,  for  which  I  would 
suggest  farina,  hominy,  or  rice,  any  of  which 
may  be  served  with  butter  and  a  little  sugar. 
If  the  child  will  not  take  the  cereals  without 
milk,  a  very  little  may  be  added.  This  with 
stewed  fruit  and  a  piece  of  bread  is  sufficient. 
The  child's  bedclothing  should  be  light,  and 
he  should  be  made  to  sleep  on  his  side,  not 
on  his  back.  In  order  to  prevent  the  child 
resting  on  his  back,  tie  a  piece  of  any  thin 
goods  about  the  chest,  with  a  large  knot  be- 
tween the  shoulders.  The  child  should  always 
be  taken  up  at  ten  or  eleven  o'clock  and  made 
to  urinate. 


Care  of  the  Genitals       273 

If  there  is  phimosis,  vaginitis,  thread- worms, 
or  any  local  disorders,  treatment  of  the  local 
conditions  may  effect  a  cure. 

Incontinence  during  the  day. — A  few  bed- 
wetting  children  are  troubled  with  incontinence 
during  the  day  as  well.  There  is  a  constant 
leakage,  the  clothing  being  wet  the  greater 
part  of  the  time.  The  management  of  these 
cases,  however,  differs  in  no  respect  from  that 
advised  for  those  first  mentioned,  except  in 
the  matter  of  medication,  which  can  be  carried 
out  only  by  a  physician. 

CARE  OF  THE  GENITALS 

PAINFUL  MICTURITION,  CIRCUMCISION 

In  girls  very  little  care  of  the  genitals  is 
required  other  than  cleanliness.  The  parts 
should  be  washed  in.  boiled  water  and  Castile 
soap  once  a  day.  Sponges  should  not  be  used. 
Soft  old  linen  is  far  better,  and  after  once 
using  it  should  be  burned.  A  sponge  is  never 
clean  after  it  has  once  been  used,  and  should 
have  no  place  in  the  nursery  outfit.  After 
cleansing,  the  parts  should  be  dusted  thor- 
oughly with  the  following  powder:  boracic 


274       Care  of  the  Genitals 

acid  ten  grains,  powdered  starch  and  oxide  of 
zinc  each  one-half  ounce. 

With  boys  more  attention  is  required.  The 
normal  condition,  a  free  foreskin,  non-adherent 
to  the  glans  penis,  is  necessary  for  his  comfort 
and  health.  It  should  be  stripped  back  once  a 
day  and  the  parts  washed  very  gently  with 
Castile  soap  and  warm  water,  dried  with  ab- 
sorbent cotton,  and  a  bit  of  vaseline  applied. 
In  the  majority  of  boys  the  foreskin  at  birth 
is  tightly  adherent  to  the  glans,  with  only  a  pin- 
hole  opening.  Such  a  condition  is  one  of  much 
annoyance  to  the  child.  Secretions  which  act 
as  a  foreign  body  form  under  the  foreskin, 
producing  no  little  irritation,  drawing  the 
child's  attention  to  the  parts,  and  thus  often 
leading  directly  to  the  habit  of  masturbation. 
Inflammation  of  the  foreskin  and  orifice  of  the 
urethra  not  infrequently  follows  this  condition. 
As  a  result,  urination  is  painful  and  the  urine 
is  retained  until  the  child  cannot  pass  it.  I 
have  known  children  for  this  reason  to  hold 
their  urine  for  over  twenty- four  hours.  I  have 
known  pus  to  form  under  the  foreskin,  neces- 
sitating immediate  operation.  In  two  boys 
aged  about  two  years,  repeated  convulsions 
occurred,  for  which  no  reason  could  be  as- 


Retention  of  Urine        275 

signed  other  than  the  irritation  caused  by  the 
tightly  adherent  foreskin  and  the  retained  se- 
cretions. They  were  circumcised  and  have 
been  perfectly  well  since.  Bed-wetting  is  often 
a  direct  outcome  of  this  trouble. 

Necessity  of  circumcision. — Four  out  of 
five  of  the  boys  who  come  under  my  care  need 
circumcision.  This  does  not  mean  that  four 
out  of  five  are  circumcised,  as  family  objec- 
tions are  often  hard  to  overcome,  even  where 
the  physician  is  convinced  that  such  a  measure 
would  be  beneficial.  In  a  very  few  cases, 
stretching  and  retracting  the  foreskin  may 
answer  every  purpose.  But  such  cases  are 
rarely  properly  attended  to  afterward;  no  mat- 
ter how  careful  the  instructions  given,  the  adhe- 
sions are  allowed  to  re-form,  and  in  a  short 
times  all  the  annoying  symptoms  return.  The 
daily  manipulation  of  the  parts  necessary  for 
cleanliness  is  for  obvious  reasons  to  be  avoided 
if  possible.  When  a  child  is  properly  circum- 
cised he  is  relieved  for  all  time. 

RETENTION  OF  URINE 

This  condition  often  greatly  alarms  mothers. 
In  girls,  the  most  frequent  cause  is  pain  due 


276         Retention  of  Urine 

to  the  inflammation  of  the  urethral  orifice  and 
the  adjoining  parts,  which  may  have  been 
caused  either  by  excessive  acidity  of  the  urine, 
or  by  vaginitis.  Retention  sometimes  results 
from  taking  cold;  high  fever  is  sometimes  a 
cause,  and,  in  some  instances,  no  cause  can  be 
discovered. 

In  boys  the  retention  may  be  due  to  urethral 
irritation  produced  by  excessive  acidity  of  the 
urine;  far  more  frequently,  however,  the 
trouble  is  caused  by  an  inflammation  of  the 
foreskin,  which  is  often  swollen  to  three  or 
four  times  its  normal  size.  In  these  cases  the 
orifice  of  the  urethra  will  usually  be  found  red 
and  swollen.  In  either  sex,  if  there  is  reten- 
tion of  the  urine  for  over  sixteen  hours,  place 
the  child  in  a  tub  of  warm  water  at  a  tempera- 
ture of  no°F.,  and  often  urination  will  fol- 
low immediately.  Another  useful  method  of 
treatment  consists  in  the  application  to  the 
parts  of  cloths  wrung  out  of  hot  water.  Per- 
haps the  best  results  are  obtained  by  the  use  of 
an  enema  of  a  normal  salt  solution — a  tea- 
spoonful  of  salt  to  a  pint  of  water — at  a  tem- 
perature of  no°F. ;  at  least  a  pint  should  be 
used  for  this  purpose  and  the  child  allowed  to 
retain  it  if  he  will.  This  treatment  rarely  fails. 


Worms  277 

If  it  does,  the  doctor  must  use  the  catheter. 
The  swelling  of  the  parts  in  boys  is  best  re- 
duced by  a  wet  dressing  of  a  saturated  solution 
of  boracic  acid,  which  is  applied  on  old  linen 
wrapped  around  the  parts  and  changed  every 
half-hour.  In  girls  a  simple  pad  composed  of 
several  layers  of  old  linen  should  be  saturated 
with  the  boracic  acid  solution  and  similarly 
applied,  the  dressing  being  changed  every  hour, 
and  the  parts  gently  bathed  with  the  solution. 

WORMS 

There  are  three  varieties  of  worms  com- 
monly met  with  in  children :  the  round-worm, 
the  thread-worm,  and  the  tape-worm. 

Round-worms  occur  most  frequently  in 
children  from  two  to  ten  years  of  age,  although 
no  age  is  exempt.  When  a  child  picks  its  nose, 
grinds  its  teeth  at  night,  sleeps  poorly,  has  a 
coated  tongue,  and  an  indifferent  appetite,  it  is 
supposed  by  the  older  members  of  the  family 
to  have  "worms."  These  symptoms  may  indi- 
cate the  round-worms,  but  they  far  more  fre- 
quently indicate  a  too  close  acquaintance  with 
gingerbread  and  jam  and  other  cupboard,  be- 
tween-meal  indulgences.  Frequent  attacks  of 


278  Worms 

colic,  constipation,  alternating  with  diarrhoea 
and  convulsions  are,  in  my  judgnient,  the  most 
reliable  symptoms  of  round- worms.  The  only 
positive  means  of  diagnosis,  however,  is  the 
discovery  of  the  worm  itself,  or  the  presence 
of  the  eggs  in  the  stools.  The  round-worm 
resembles  the  common  earth-worm.  It  is 
usually  from  five  to  nine  inches  in  length  and 
inhabits  the  small  intestine.  Round-worms  are 
seldom  seen  among  city  children;  in  the  coun- 
try, however,  they  occur  with  much  greater 
frequency. 

Thread-worms  inhabit  the  lower  portion  of 
the  large  intestine,  and  in  appearance  are  like 
pieces  of  white  thread.  They  are  usually 
from  one-quarter  to  one-half  inch  in  length. 
They  are  very  frequently  seen  among  the  chil- 
dren of  the  tenements.  Occasionally  they  oc- 
cur in  children  of  the  well-to-do. 

The  chief  symptom  of  these  worms  is  an 
itching  or  irritation  about  the  anus.  The  child 
is  restless  and  sleeps  poorly.  In  girls  there 
may  be  a  vaginal  discharge  due  to  the  irrita- 
tion caused  by  the  worms,  which  have  migrated 
to  these  parts.  Frequently  the  only  symptoms 
of  discomfort  will  be  manifested  when  the 
child  is  put  to  bed.  He  will  then  complain  of 


Worms  279 

a  biting,  burning  sensation  in  the  rectum.  In 
some,  the  rectal  irritation  is  so  great  as  to 
cause  very  pronounced  nervous  symptoms. 

Several  years  ago  I  treated  a  six-year-old 
girl  for  involuntary  movement  of  the  arm  and 
shoulders  somewhat  resembling  St.  Vitus's 
dance.  The  trouble  disappeared  after  several 
weeks'  treatment  for  the  thread-worms  which 
were  present  in  large  numbers.  I  have  seen 
many  cases  of  prolapse  of  the  bowel  due  to  the 
straining  which  was  caused  by  the  irritant  ac- 
tion of  the  worms.  In  both  sexes  they  may 
be  a  cause  of  bed-wetting  and  in  the  girls  are 
not  an  infrequent  cause  of  masturbation.  In 
some  instances  after  treatment  the  worms  will 
be  passed  in  great  numbers  in  the  stools,  and 
may  sometimes  be  seen  adhering  to  the  skin 
of  the  parts. 

Tape-worms  in  children  are  very  rarely 
seen  in  this  country.  I  have  seen  about  fifteen 
cases  among  many  thousands  of  children 
treated  during  the  past  thirty  years.  The  pres- 
ence of  the  tape-worm  is  indicated  by  various 
indefinite  manifestations.  Constipation  alter- 
nating with  diarrhoea  are  prominent  symptoms. 
The  child  is  often  ravenously  hungry.  A  posi- 
tive diagnosis  can  be  made  only  after  the  dis- 


280  Excitement 

charge  of  segments  of  the  worm,  which  appear 
like  short  pieces  of  narrow  white  tape  linked 
together.  A  physician  should  always  direct 
the  treatment. 

EXCITEMENT 

A  baby  should  not  be  subjected  to  excite- 
ment or  its  equivalent — too  active  entertain- 
ment. The  nervous  system  of  an  infant  is 
in  such  an  undeveloped  state  that  what  would 
be  a  decided  tax  upon  it  cannot  be  appreciated 
by  adults,  who  are  often  apparently  insensible 
of  the  fact  that  children  are  different  from 
themselves. 

The  first  child  in  a  well-to-do  family  is 
usually  the  greatest  sufferer  from  superfluous 
attention, — being  a  source  of  unending  ad- 
miration on  the  part  of  the  family  and  friends. 
He  is  often  present  very  early  in  life  at  all 
important  functions.  Christmas,  Thanks- 
giving, birthday  celebrations,  and  afternoon 
teas  find  him  the  centre  of  attraction.  He  is 
handed  from  one  guest  to  another  and  is  tossed 
upon  various  angular  knees.  He  is  kissed  by 
lips  which  dare  touch  only  those  who  cannot 
protect  themselves.  He  is  talked  to  with  a 


Kissing  281 

very  loud  voice  in  a  very  silly  manner  and 
grimaces  horrible  to  witness  are  made  at  him. 
I  have  witnessed  such  scenes,  and  have  treated 
exhausted  infants  who  require  medical  atten- 
tion after  the  seance  was  over.  I  have,  indeed, 
seen  infants  thus  brought  to  the  verge  of  col- 
lapse. One  child  of  eleven  months  had  con- 
vulsions which  were  indirectly  due  to  fatigue 
incident  to  a  Thanksgiving  celebration. 
/ 

KISSING 

A  child  should  never  be  kissed  on  the  mouth. 
I  have  known,  in  my  own  private  practice,  of 
instances  where  tuberculosis,  diphtheria,  and 
syphilis  have  been  communicated  from  the  dis- 
eased adult  to  the  child  by  this  practice. 
Neither  should  the  child's  hands  or  fingers  be 
kissed,  as  the  hands  and  fingers  of  the  ma- 
jority of  babies  are  in  their  mouths  many 
times  an  hour.  If  baby  is  the  first  one  that  has 
graced  the  household,  and  must  be  kissed,  this 
can  be  accomplished  with  the  least  damage  if 
the  kiss  is  implanted  on  the  head  or  forehead. 
The  parents  must  make  the  rule,  and  they  must 
set  the  example  by  adhering  to  it  themselves. 

Among  my  patients,  a  nurse  who  is  known 


282  Sleep 

to  have  kissed  the  child  is  punished  by  dis- 
missal. Because  an  adult  is  apparently  well 
is  no  excuse  for  this  indulgence.  Healthy 
adults  frequently  have  in  their  mouths  the 
germs  of  tuberculosis,  of  diphtheria,  of  grippe, 
and  of  other  diseases,  and  never  suffer  from 
their  presence  because  they  are  strong  adults 
with  vigorous  mucous  membranes  which  do 
not  furnish  as  favorable  a  soil  for  the  growth 
and  development  of  pathogenic  bacteria  as  do 
the  more  delicate  mucous  membranes  of  the 
young.  It  is  criminal,  therefore,  to  subject  the 
child  to  such  dangers.  Scarlet  fever,  measles, 
and  whooping-cough  are  all  most  readily  trans- 
mitted at  the  beginning  of  an  attack  through 
the  close  contact  required  by  a  kiss. 

SLEEP 

The  infant  that  sleeps  well  is  almost  always 
a  normal,  well-fed  baby.  Irritability  and 
sleeplessness  are  associated  with  indigestion 
more  frequently  than  with  any  other  disorder. 
During  the  first  few  days  of  life  the  sleep, 
in  normal  conditions,  is  almost  unbroken,  ex- 
cept when  the  infant  is  fed.  During  the  first 
month  the  infant  sleeps  about  twenty-two 


Sleep  283 

hours  out  of  every  twenty- four;  during  the 
second  and  third  months,  from  twenty  to 
twenty-two  hours.  At  the  sixth  month  the 
child  should  sleep  from  6  P.M.  to  6  A.M.  with- 
out interruption  other  than  for  feeding  or 
nursing,  which  need  cause  very  little  dis- 
turbance. At  this  age  there  should  be  a  two- 
hour  nap  during  the  morning  and  a  two-hour 
nap  in  the  afternoon,  although  it  is  not  well 
to  have  the  baby  sleep  after  three  o'clock  in 
the  afternoon.  The  twelve-hour  night  rest 
should  be  continued  until  the  child  is  six  years 
of  age.  The  day  naps  will  gradually  be  short- 
ened by  the  child.  At  one  year  of  age,  one 
hour  in  the  morning  and  two  hours  in  the 
afternoon  suffice.  From  the  eighteenth  month 
to  the  second  year,  the  morning  nap  is  given 
up.  Afternoon  rest  for  at  least  one  and  one- 
half  hours  should  be  continued  until  the  child 
is  six  years  of  age,  and  longer  if  he  is  inclined 
to  be  delicate.  Regular  sleep  is  largely  a  mat- 
ter of  habit,  and  if  the  infant  is  started  right, 
with  suitable  feedings  given  at  definite  times, 
followed  by  the  proper  period  of  sleep,  but 
little  trouble  will  be  experienced  with  sleepless- 
ness. When  sleep  is  disturbed  and  broken,  it 
means  bad  habits,  unsuitable  food,  minor  forms 


284  Crying 

of  indigestion,  or  positive  illness  of  some  kind. 
Sleep  is  important  for  purposes  of  growth  not 
only  in  early  infancy  but  throughout  childhood. 
Not  a  few  infants  form  habits  of  sleeping  in 
the  daytime  and  being  wakeful  at  night.  This 
is  best  remedied  by  keeping  the  baby  awake 
when  he  should  be,  during  the  day,  by  enter- 
tainment and  by  keeping  him  in  a  well-lighted 
room.  I  am  sure  that  the  satisfactory  results 
I  have  had  the  good  fortune  to  achieve  in  the 
treatment  of  secondary  malnutrition  and  ane- 
mia have  been  due  in  part  to  my  insistence  that 
the  child  sleep  in  a  quiet,  darkened  room  for 
two  hours  after  the  noonday  meal.  The  energy 
expended  in  twelve  hours  by  an  active  child 
is  incalculable,  and  when  a  portion  of  this 
energy  is  reserved  and  the  body  fortified  by 
rest  and  sleep  during  the  middle  of  the  day, 
it  means  a  greatly  diminished  daily  expenditure 
of  strength  units. 

CRYING 

It  is  well  for  the  young  infant  to  cry  a  little 
every  day.  Muscular  movements  involving 
a  greater  part  of  the  body  accompany  the  act 
of  crying  and  furnish  exercise.  Peristalsis  is 


Crying  285 

increased,  as  is  often  evidenced  by  a  move- 
ment of  the  bowels  occurring  at  the  time,  par- 
ticularly when  there  is  diarrhoea.  In  crying, 
deep  breathing  is  necessary,  the  lungs  are  ex- 
panded, and  the  blood  oxygenated.  The  well 
baby  cries  when  frightened,  or  uncomfortable 
from  hunger,  soiled  napkins,  or  inflamed  but- 
tocks. He  cries  from  pain,  from  heat,  from 
cold,  from  unsuitable  clothing,  and  during  diffi- 
cult evacuation  of  the  bowels.  He  also  cries 
when  displeased  or  angry.  Authors  are  prone 
to  refer  to  the  diagnostic  value  of  an  infant's 
cry.  It  is  my  belief  that  characteristic  cries 
are  not  to  be  depended  upon  sufficiently  to  give 
them  a  differential  diagnostic  dignity.  Children 
slightly  but  painfully  ill  may  cry  incessantly 
for  an  hour  or  two.  Thus,  with  intes- 
tinal colic,  where  the  cry  is  loud  and  continu- 
ous until  the  child  is  relieved  or  until  he  falls 
asleep  from  exhaustion.  Earache  is  not  an 
infrequent  cause.  The  habitual  criers,  the  rest- 
less and  vigorous  crying,  whining  infants,  are 
uncomfortable.  With  very  few  exceptions  the 
trouble  will  be  found  in  the  intestinal  tract. 
The  well-trained,  normal  child,  whose  nourish- 
ment is  suitable,  is  seldom  troublesome.  When 
well,  all  babies  are  naturally  good-natured  and 


286  Cleanliness 

happy  in  their  own  way.  Badly  managed, 
spoiled  infants  often  cry  vigorously  when  left 
alone.  When  attention  is  given  them,  when 
they  are  taken  up  and  talked  to,  the  crying 
ceases.  This  readily  tells  us  that  pain  or  dis- 
comfort was  not  an  element  in  causing  the  cry. 
In  these  infants,  discipline,  not  medication,  is 
needed.  The  management  of  the  habitual  crier 
involves  the  relief  of  the  condition  which  causes 
the  discomfort,  or  the  most  rigid  discipline. 

CLEANLINESS 

Much  has  been  said  and  written  regarding 
the  necessity  of  cleanliness  so  far  as  the  child 
is  concerned;  but  not  only  should  the  nurse 
and  mother  see  that  the  baby  is  clean;  they 
must  be  clean  themselves.  Immediately  after 
every  attention  to  the  napkin  the  hands  should 
be  washed  with  hot  water  and  soap  and  a  stiff 
brush.  This  cleansing  process  must  be  re- 
peated before  the  preparation  of  the  food  or 
any  manipulation  of  the  feeding  apparatus. 

The  child's  attendants  should  not  have  de- 
cayed or  neglected  teeth.  The  tooth-brush 
should  be  an  important  article  in  the  outfit  of 
every  nurse.  She  should  take  a  tub-bath  or 


Cold  Hands  and  Feet      287 

sponge-bath  daily.  The  hands  and  finger- 
nails of  many  nursery-maids  will  bear  watch- 
ing. 

COLD  HANDS  AND  FEET 

The  hands  and  feet  of  the  infant  should 
never  be  cold  to  the  touch.  This  is  a  cause 
of  much  of  his  discomfort  and  restlessness. 
A  very  young  child  with  poor  circulation  will 
be  made  much  more  comfortable  by  placing  a 
hot-water  bag  at  his  feet.  Bottles  filled  with 
warm  water  and  wrapped  in  flannel  will  keep 
the  upper  extremities  warm.  In  using  the  hot- 
water  bags  and  bottles  be  sure  that  the  water 
is  not  too  hot.  Severe  burning  accidents  have 
resulted  from  carelessness  in  this  particular. 

An  excellent  means  of  keeping  premature 
or  delicate  babies  warm  is  in  the  use  of  the 
"  Elect  rotherm"  (Fig.  12).  These  small 
heaters  are  attached  to  an  electric  fixture,  like 
a  drop-light.  A  convenient  size  is  from  ten  to 
fifteen  inches.  It  is  placed  between  two  or 
three  thicknesses  of  blankets,  upon  which  the 
infant  lies  in  its  basket  or  crib.  The  degree  of 
heat  can  be  regulated  according  to  the  amount 
of  electricity  turned  on. 


288       Flies  and  Mosquitoes 

FLIES  AND  MOSQUITOES 

The  windows  of  the  nursery  should  be 
screened  so  that  flies  and  mosquitoes  cannot 
enter.  When  out  of  doors  the  very  young 
child  should  be  protected  by  mosquito-netting. 
Mosquitoes  severely  poison  many  children,  and 
are  of  especial  danger  in  that  one  variety  is 
capable  of  inoculating  the  child  with  malaria, 
the  Plasmodium  malaria  being  deposited  along 
with  the  other  poison. 

Flies,  in  addition  to  disturbing  sleep,  are  a 
source  of  much  danger  which  is  but  little  ap- 
preciated. The  fly  enters  the  nursery  and 
alights  on  the  nipple  of  the  nursing-bottle. 
This  may  take  place  while  the  child  is  resting 
for  a  second  or  two  during  his  meal,  as  flies 
are  very  fond  of  the  sweet  milk  which  may 
adhere  to  the  nipple ;  or  the  fly  may  alight  upon 
the  child's  bread,  or  the  prepared  cereal,  or 
any  article  of  food,  particularly  if  there  is  a 
sweet  element  in  it.  The  last  place  the  fly 
rested  before  reaching  the  nursery  we  never 
know.  It  may  have  been  on  animal  excrement, 
or  tubercular  sputum,  or  the  infectious  dis- 
charges of  a  typhoid- fever  patient.  In  this  way 
the  flies'  feet  and  legs  are  the  means  of  trans- 


Germs  289 

porting  the  germs  of  typhoid  fever  or  diph- 
theria. Tuberculosis  is  unquestionably  trans- 
ferred in  this  way  very  frequently,  minor  ail- 
ments with  still  greater  frequency.  Flies  are 
a  source  of  danger  in  the  house,  and  should  be 
driven  out  or  destroyed. 

GERMS 

What  need  has  the  mother  to  know  about 
germs?  She,  of  all  persons,  should  know  be- 
cause nearly  all  the  illnesses  of  an  infant  and 
child  life  are  due  to  invisible  bodies,  some  so 
tiny  that  the  most  powerful  microscope  fails  to 
detect  them. 

The  following  is  a  list  of  some  of  the  diseases 
which  have  been  proven  due  to  germs  or  bac- 
teria : 

Consumption  (Tuberculosis), 

Meningitis, 

Cholera, 

Typhoid  fever, 

Infantile  paralysis, 

Diphtheria, 

Whooping-cough, 

Cholera  infantum, 

Dysentery, 

Summer  diarrhoea, 

19 


290  The  Doctor 

Grippe, 

Pneumonia, 

Bronchitis. 

Scarlet  fever,  smallpox,  measles,  mumps, 
chicken-pox,  and  others  are  of  germ  origin, 
but  the  particular  germ  causing  each  disease 
has  not  been  proven. 

Boiling,  sterilizing,  and  the  use  of  soap  and 
hot  water  for  scrubbing  purposes,  together 
with  sunlight  and  fresh  air  and  the  destruc- 
tion of  flies,  mosquitoes,  and  other  insects  are 
the  great  means  of  combating  germ  life. 

WHEN  TO  SEND  FOR  THE  DOCTOR 

This  question  is  easily  answered.  Send 
for  the  doctor  when  there  are  any  indica- 
tions of  illness  in  the  child  which  the  mother 
does  not  understand.  It  is  better  to  be  over- 
cautious in  this  respect  than  to  join  the  great 
number  of  mothers  who  are  never  free  from 
the  bitter,  life-long  regret,  "The  child  might 
have  been  saved  had  he  been  treated  in  time." 
I  know  such  mothers. 

There  are  two  conditions  in  which  the 
mother  must  not  trust  herself  for  a  moment. 
These  are  summer  diarrhoea,  and  sore  throat. 


First  Aid  to  the  Baby      291 

"Only  a  summer  diarrhoea,"  and  "only  a 
sore  throat,"  and  "only  a  teething  diarrhoea," 
have  sacrificed  the  lives  of  hundreds  of  infants. 
Diphtheria  is  a  very  prevalent  disease,  and 
the  successful  treatment  of  it  requires  that 
the  child  be  seen  by  the  physician  at  the 
earliest  possible  moment.  So,  also,  with  sum- 
mer diarrhoea.  I  have  seen  infants  die  in 
twelve  hours  with  the  disease.  Calling  a  doc- 
tor early  is  a  means  not  only  of  safety,  but  of 
economy.  In  the  correction  of  slight  ailments, 
grave  ones  are  avoided. 

FIRST  AID  TO  THE  BABY 

Cuts. — Keep  fingers,  water,  clothing,  dust 
— everything  away  from  the  wound.  Mix 
one  teaspoonful  of  tincture  of  iodine  with 
the  same  quantity  of  alcohol,  and  paint  this 
solution  on  the  skin  about  the  wound,  from 
the  very  edges  of  the  wound  to  at  least  two 
inches  away  on  all  sides,  provided  of  course 
that  the  part  injured  will  permit  of  this  wide 
application.  Then  apply  a  freshly  ironed 
piece  of  linen  and  a  bandage.  This  dressing 
must  be  kept  in  place. 

Bruises  and  bumps. — Apply  cloth  wrung  out 
in  cold  water.  Change  frequently. 


292      First  Aid  to  the  Baby 

Sprains. — Wrap  a  bandage  around  the  part 
and  keep  wet  with  cold  water  in  frequent  ap- 
plication. If  the  injured  part  is  a  lower 
extremity,  keep  it  elevated  on  a  plane  with  the 
body. 

Cuts,  bruises,  and  sprains  of  consequence 
require  the  early  attention  of  the  family 
physician. 

Burns. — If  the  skin  is  merely  reddened, 
apply  vaseline  or  sweet  oil  on  clean  linen.  If 
the  skin  is  blistered  or  charred,  do  not  apply 
any  oily  substance.  Sprinkle  boric  acid  powder 
over  the  parts  and  cover  with  clean  linen  until 
the  physician  arrives. 

Bites  of  animals. — Bites  of  animals  are 
rarely  serious.  Hundreds  of  individuals  are 
bitten  by  dogs  and  cats  every  year  without 
other  harm  than  that  of  the  wound  inflicted. 
Apply  at  once  on  old  linen  a  solution  of  one 
teaspoonful  of  carbolic  acid  in  one  pint  of 
water  or  one  ounce  of  boracic  acid  in  one  pint 
of  water.  Keep  this  dressing  wet  on  the 
wound  until  a  physician  is  seen. 

Bites  of  insects. — Bites  of  insects  may  be 
dangerous.  Mosquitoes  can  transmit  malaria 
and  yellow  fever.  Insect  bites,  although  inno- 
cent of  great  harm,  cause  a  great  deal  of  dis- 


First  Aid  to  the  Baby      293 

comfort  through  itching  and  temporarily  dis- 
figure the  child.  The  itching  attending  insect 
bites  particularly  in  the  case  of  mosquitoes  is 
greatly  relieved  by  painting  the  parts  with 
collodion  containing  10%  solution  of  tincture 
of  iodine.  Frequent  applications  of  witch  hazel 
are  helpful  in  relieving  the  patient. 

Fever. — The  onset  of  sudden  fever  is  to  be 
met  by  a  dose  of  castor  oil,  one  to  two  tea- 
spoonfuls,  a  bowel  irrigation  (p.  109)  if  there 
has  been  constipation,  and  a  sponge  bath  (p. 
114)  with  cool  water.  The  sponging  may  be 
continued  for  from  fifteen  to  twenty  minutes. 

Colic. — An  attack  of  colic  is  best  relieved 
by  a  bowel  irrigation  (p.  109) ,  by  giving  sips  or 
teaspoonful  doses  of  quite  hot  water.  A 
soda  mint  tablet  dissolved  in  one  ounce  of 
hot  water  and  given  in  teaspoon  doses  every 
five  minutes  will  relieve  many  cases.  The  food 
should  be  temporarily  discontinued  and  water 
given.  If  the  child  has  colic  habitually  it 
means  that  the  food  given  needs  the  attention 
of  a  physician. 

Convulsions. — While  awaiting  the  physician 
place  the  baby  in  a  warm  bath  and  rub  the  body 
vigorously  while  in  the  bath.  If  mustard  is 
at  hand  add  two  teaspoon fuls  to  the  water  used. 


294      First  Aid  to  the  Baby 

The  great  majority  of  convulsions  are  due  to 
indigestion  and  constipation.  Give  the  baby 
an  enema  as  soon  as  possible,  perhaps  while 
in  the  bath.  As  soon  as  the  baby  can  swallow 
give  two  teaspoonfuls  of  castor-oil.  For  a 
few  days  following,  a  greatly  reduced  diet 
should  be  given. 

Earache. — 1st.  Drop  warmed  sweet  oil  into 
the  ear.  Test  it  in  your  own  ear  first  to  insure 
its  not  being  too  hot. 

2d.  Rest  the  affected  side  on  a  hot-water  bag. 

3d.  Syringe  the  ear  (page  117)  with  water 
at  110°  F.  If  a  thermometer  is  not  at  hand, 
have  the  water  quite  warm  and  test  the  heat 
of  the  water  in  your  own  ear  before  using. 

Nose-bleed. — The  child  should  sit  erect,  not 
lie  down.  The  nose  should  be  firmly  com- 
pressed between  the  thumb  and  finger  for 
several  minutes.  The  tips  of  the  thumb  and 
finger  should  touch  the  lower  portion  of  the 
nasal  bones.  After  the  bleeding  is  controlled 
in  this  way,  a  small  piece  of  ice  should  be 
wrapped  in  a  handkerchief  and  held  against  the 
affected  side.  Repeated  hemorrhage  usually 
means  that  an  ulcer  is  present  in  the  nostrils 
and  needs  active  treatment. 

Foreign  bodies  swallowed. — Foreign  bodies 


First  Aid  to  the  Baby      295 

swallowed  by  infants  and  young  children  rarely 
cause  harm.  Do  not  give  a  laxative.  Give 
starchy  substances  such  as  oatmeal,  potato, 
cornmeal  mush,  substances  which  may  form 
a  semi-solid  mass  in  the  intestine  in  which  the 
object  swallowed  may  become  imbedded  and 
carried  forward. 

Foreign  bodies  in  nose  and  ear. — A  foreign 
body  in  either  nostril  may  sometimes  be  re- 
moved by  making  pressure  over  the  unob- 
structed nostril  and  then  directing  the  child 
to  blow  the  nose  vigorously. 

Substances  not  thus  removed,  as  well  as  for- 
eign bodies  in  the  ear,  should  be  removed  only 
by  a  physician. 

Prickly  heat. — Prickly  heat  is  best  treated 
by  sponge  baths  of  bicarbonate  of  soda,  one 
tablespoonful  to  two  quarts  of  water.  Do  not 
rub  the  skin  in  drying.  Several  times  a  day 
dust  the  skin  thoroughly  with  a  powder  com- 
posed of  equal  parts  of  powdered  starch  and 
oxide  of  zinc,  obtained  at  the  druggist's.  Chil- 
dren with  prickly  heat  should  wear  thin  gauze 
or  linen  underwear.  Wool  should  not  be  worn. 

Croup. — There  are  two  kinds  of  croup, 
catarrhal  or  spasmodic  and  diphtheritic  or 
membranous  croup. 


296      First  Aid  to  the  Baby 

Croup  always  calls  for  the  immediate  atten- 
tion of  a  physician.  While  waiting  for  the 
doctor,  give  the  patient  a  teaspoonful  of  syrup 
of  ipecac  to  be  repeated  in  15  minutes,  if 
vomiting  does  not  occur.  The  child  is  much 
relieved  by  vomiting,  if  the  case  is  one  of 
spasmodic  croup.  Steam  inhalation  from  a 
croup  kettle  or  a  tea-kettle  are  of  much  service. 
Care  must  be  exercised  not  to  burn  the  child. 

Sore  throat. — A  mother  must  never  attempt 
to  treat  a  sore  throat  in  a  child.  Diphtheria 
usually  begins  with  low  fever  and  a  slight  sore 
throat.  A  physician  should  be  called  in  every 
case  of  sore  throat  in  a  child.  I  could  give 
many  instances  in  which  children  have  died 
with  diphtheria  because  of  neglected  ''home- 
treated"  sore  throat. 

The  swallowing  of  poisons. — Unfortunately 
children  are  sometimes  given  the  wrong  medi- 
cine, or  given  some  poisonous  substance  instead 
of  the  medicine  intended.  I  have  known  chil- 
dren to  swallow  poisonous  tablets  and  pills  in- 
tended for  adults.  Under  such  circumstances 
the  child  should  always  be  made  to  vomit.  This 
can  be  done  by  gagging  the  child  through  forc- 
ing- the  clean  index  finger  low  in  throat.  If 
syrup  of  ipecac  is  at  hand  two  teaspoon fuls 


Patent  Medicines— Resorts    297 

may  be  given,  which  will  be  sufficient  to  pro- 
duce active  vomiting.  The  physician  must  be 
called  at  once  in  all  cases  of  poisoning. 

PATENT  MEDICINES 
\ 
Patent  medicines  should  form  no  part  of 

the  nursery  outfit.  The  mother's  home  reme- 
dies should  all  be  approved  by  a  physician. 
Cough  mixtures  and  soothing  syrups,  the  ad- 
vantages of  which  are  so  faithfully  portrayed 
in  the  popular  magazines  and  religious  periodi- 
cals, are  often  very  harmful.  Most  of  them 
contain  alcohol,  opium,  or  morphine.  Time 
and  again  I  have  seen  children  drugged  to  the 
point  of  stupor  by  these  remedies. 

SUMMER  RESORTS 

Where  to  take  the  child  for  the  summer  is 
a  vexed  question  which  arises  once  a  year  in 
many  households.  Several  years  of  observa- 
tion of  a  great  many  children  who  have  spent 
the  summer  out  of  town  have  led  me  to  the 
following  conclusions : 

1.  The  most  desirable  summer  outing:  the 
first  half  of  the  season  at  the  seashore,  the  re- 
mainder inland,  preferably  in  the  mountains. 

2.  The   next   in   order   of   desirability:   in- 


298          Summer  Resorts 

land,  preferably  the  mountains  for  the  entire 
summer. 

3.  The  least  desirable :  the  seashore  for  the 
entire  summer. 

I  do  not  wish  it  understood  that  many  chil- 
dren will  not  do  well  at  the  seashore  if  kept 
there  the  entire  summer;  some,  indeed,  im- 
prove wonderfully;  but  among  my  own 
patients  I  have  been  repeatedly  impressed  with 
the  disadvantages  of  a  prolonged  outing  by 
the  sea.  The  seashore  children,  as  a  rule,  do 
not  return  to  the  city  in  the  fall  with  the  vigor, 
appetite,  and  general  robustness  which  charac- 
terize those  who  return  from  the  mountains.  I 
refer  only  to  New  York  children,  whose  home 
is  a  seaport,  and  who  thrive  best  when  given 
the  advantage  of  a  complete  change  to  the  dry, 
invigorating  air  of  the  mountains.  Children 
with  catarrhal  tendencies,  adenoids,  bronchitis, 
and  rheumatism,  and  those  convalescent  from 
pneumonia,  should  not  go  to  the  seashore. 

In  selecting  an  inland  resort,  the  mountains, 
by  which  we  understand  an  elevation  of  from 
fifteen  hundred  to  two  thousand  feet,  are  not 
always  necessary.  The  place  selected,  how- 
ever, should  have  an  elevation  of  at  least  six 
hundred  feet,  and  should  not  be  within  sixty 


Drug-Giving  299 

miles  of  the  coast.  Children  who  are  subject 
to  rheumatism  and  bronchitis  do  best  on  a 
sandy  soil,  in  a  dry  climate,  with  the  sleeping 
rooms  above  the  ground  floor. 

Another  point  to  be  considered  in  this  con- 
nection is  the  kitchen  facilities  which  will  be 
provided  for  the  preparation  of  the  child's 
food.  As  a  rule,  the  larger  hotels  refuse  the 
right  of  way  to  the  kitchen;  or,  if  they  do  not, 
it  is  at  the  expense  of  many  material  atten- 
tions to  the  chef.  I  find  that  mothers  are  given 
much  more  latitude  as  to  these  matters  in  the 
smaller  hotels  and  boarding-houses.  The 
proper  preparation  of  a  child's  food  in  the 
cramped  quarters  of  the  sleeping  apartment 
is  not  impossible,  but  it  is  very  difficult. 

Before  selecting  a  summer  home,  the  drain- 
age, the  milk,  and  the  water  supply  must  be 
considered.  If  the  parents  possess  the  means, 
a  cottage  should  be  rented,  which  will  insure 
them  all  the  comforts  of  home.  Country  well 
water  or  spring  water  should  always  be  boiled 
before  using. 

DRUG-GIVING 

Drugs  are  of  service  only  in  the  hands  of 
those  who  are  trained  in  their  use.  Mothers 


300         The  Daily  Outing 

often  acquire  the  habit  of  treating  their  chil- 
dren. Self -prescribing  is  greatly  overdone  in 
this  country  among  all  classes.  Many  people 
know  just  enough  about  medicines  to  be  dan- 
gerous members  of  society.  The  proprietary 
cough  mixtures,  soothing  syrups,  teas,  car- 
minatives, etc.,  are  often  injurious.  They 
usually  contain  opium, — a  drug  which  a  mother 
should  never  think  of  giving  her  baby  on  her 
own  responsibility.  It  is  not  at  all  uncommon 
in  hospital  work  to  have  children  admitted  in 
an  opium  stupor  which  resists  all  treatment 
for  hours. 

While  the  habit  of  promiscuous  drug-giving 
is  to  be  condemned,  the  mother  is  not  supposed 
to  remain  inactive  while  awaiting  the  arrival 
of  the  physician ;  a  preliminary  dose  of  castor- 
oil  in  diarrhoea,  or  syrup  of  ipecac  in  croup,  or 
rhubarb  and  soda  when  there  is  a  furred  tongue 
in  indigestion,  will  always  be  in  order.  The 
mother  may  have  her  home  remedies,  but  the 
physician  must  instruct  her  in  their  use. 

THE  DAILY  OUTING 

The  baby  should  not  go  out  in  stormy 
weather.  If  under  one  year  of  age  he  should 


Indoor  Airing  301 

not  go  out  if  the  temperature  is  below  20°  F. 
During  the  midday  heat  of  summer  the  baby 
is  better  off  in  the  largest  and  coolest  room  in 
the  house  or  on  a  shady  veranda.  On  very 
windy  days  the  outing  should  be  postponed. 
When  the  snow  is  melting  in  large  quantities 
the  baby  is  better  off  indoors. 

INDOOR  AIRING 

For  this  purpose  the  child  is  dressed  as  for 
the  daily  outing.  All  the  windows  of  the  nur- 
sery or  some  other  large  room  are  opened,  on 
one  side  of  the  room  only.  The  doors  should 
be  closed,  so  that  currents  of  air  are  avoided. 
The  child  is  placed  in  his  carriage,  suitably 
covered,  and  wheeled  about  the  room  for  an 
hour  or  two.  This,  if  done  twice  daily,  an- 
swers almost  as  well  as  the  actual  outing. 

This  method  will  be  found  very  useful  in 
"winter  babies" — those  born  during  the  late 
fall  or  winter  months.  The  indoor  airing 
may  be  given  for  a  week  or  more,  before  he 
is  taken  out.  By  this  means  the  child  is  grad- 
ually accustomed  to  a  change  of  the  tempera- 
ture from  that  of  the  average  living-room  to 
that  of  out-of-doors,  and  will  not  be  harmed 


302         Children's  Parties 

when  he  is  finally  taken  out.  After  an  illness, 
it  will  afford  an  earlier  means  of  returning  to 
the  daily  outing.  This  method  of  giving  a 
child  fresh  air  will  be  found  useful  with  very 
delicate  children,  who,  by  reason  of  their  con- 
dition, may  be  unable  to  go  out  during  the 
winter  months  for  several  weeks  at  a  time. 
There  are,  however,  but  few  days  during  the 
winter  that  are  too  cold  or  too  stormy  for  the 
indoor  airing. 

CHILDREN'S  PARTIES 

Parties  for  children  under  the  sixth  year 
of  age  are  to  be  discouraged.  The  important 
features  of  a  child's  party  are  entertainment 
and  the  ' 'banquet."  There  are  two  features  of 
child  life  that  are  important  to  guard  against — 
excitement  and  injudicious  feeding.  Exciting 
play  and  unusual  articles  of  food  at  an  unusual 
time  appear  to  be  a  necessary  part  of  a  so- 
called  children's  party.  The  bringing  together 
of  children  of  tender  age  is  further  to  be  dis- 
couraged because  it  increases  their  liability  to 
contract  the  contagious  diseases  from  which 
every  child  should  be  protected  to  the  full  ex- 
tent of  our  ability. 


Baskets  for  Early  Exercise    303 

Not  long  since  a  patient — a  little  boy  four 
years  old — invited  fourteen  little  boys  and 
girls  of  corresponding  ages  to  celebrate  his 
birthday.  The  little  host  was  more  generous 
than  was  his  wont;  he  gave  more  than  the 
banquet!  The  night  of  the  birthday  party  he 
was  very  uncomfortable.  The  following  day 
he  developed  chicken-pox.  In  due  course  of 
time  twelve  of  the  fourteen  little  guests  came 
down  with  chicken-pox.  They  were  fortu- 
nate that  it  was  only  chicken-pox;  it  might 
have  been  scarlet  fever  or  diphtheria. 

I  regret  that  I  have  not  kept  a  record  of 
the  acute  illnesses  that  have  followed  children's 
parties  under  my  immediate  observation. 
Acute  indigestion,  diarrhoea,  convulsions,  and 
all  of  the  contagious  diseases  of  childhood 
would  be  found  in  generous  numbers  in  such 
a  record. 

BASKETS  FOR  EARLY  EXERCISE 

It  is  a  great  mistake  to  have  the  infant  con- 
stantly in  arms.  The  first  baby  suffers  more 
in  this  respect  than  later  children.  When  the 
child  is  held,  there  is  always  a  tendency  to  make 
him  sit  on  the  arm  or  knee  without  proper 


304  Baskets  for  Early  Exercise 

support,  or  to  toss  about  or  handle  him  re- 
gardless of  consequences.  The  bones  and  liga- 
ments of  the  spinal  column  are  not  sufficiently 
developed  to  bear  the  weight  of  the  heavy  head 
and  trunk,  and,  as  a  result,  as  the  child  grows 
older,  spinal  curvature  and  other  deformities 
not  infrequently  follow.  By  urging  him  to 


FIG.   19.     BASKET  FOR  EARLY  EXERCISE 

stand  on  the  lap  the  legs  are  used  more  than 
is  advisable,  and  we  find  bow-legs  or  knock- 
knees  very  prevalent. 

A  large  clothes-basket,  in  which  a  thick 
blanket  has  been  placed  (see  Fig.  19), 
furnishes  a  safe  and  satisfactory  playground. 
For  the  first  few  months  the  child  will  rest  on 
his  back  and  amuse  himself  in  his  own  pecul- 
iar way.  When  he  can  sit  up,  supported  by 


Night  Terrors  305 

a  pillow  at  his  back,  the  basket  gives  him 
plenty  of  room  for  toys  and  other  baby  re- 
quirements. In  it  the  baby  is  practically  safe. 
He  is  not  apt  to  be  injured  by  young  members 
of  the  family  in  rough  play.  He  cannot  crawl 
to  the  stove  to  be  burned,  and  is  in  no  danger 
of  rolling  down-stairs.  When  he  can  stand 
and  begins  to  walk,  the  basket  period  is  at  an 
end. 

NIGHT  TERRORS 

The  child  awakens  suddenly  from  sleep, 
cries  out  with  fear,  and  begs  to  be  protected 
from  men  and  animals,  which  he  imagines  are 
trying  to  injure  him.  In  some  cases  the  nurse 
and  immediate  relatives  of  the  family  will  not 
be  recognized.  The  seizures  may  occur  quite 
regularly  every  night  until  the  cause  is  re- 
moved. Other  children  may  have  but  one  or 
two  attacks  in  a  week.  The  seizures  are 
usually  due  to  a  disordered  digestive  tract  in 
a  nervous  child.  Adenoids  and  enlarged  ton- 
sils are  considered  by  some  to  act  as  a  predis- 
posing cause.  Anxiety  regarding  school 
duties,  or  overwork  at  school  may  help  to  bring 
on  an  attack;  worms  may  also  be  a  cause.  My 


20 


306       Scales  for  Weighing 

cases  have  all  been  due  either  to  acute  or 
chronic  digestive  disturbances  in  nervous  chil- 
dren. A  boy  patient  twelve  years  of  age  has 
had  two  attacks  every  year,  with  one  exception, 
since  he  was  six  years  old.  These  attacks 
always  occur  on  the  night  after  Christmas  and 
his  birthday,  after  indulgence  in  all  sorts  of 
unsuitable  articles  of  food. 

During  the  attack  the  child  must  be  treated 
with  gentleness;  scolding  makes  matters 
worse.  If  possible,  he  should  be  induced  to 
go  to  sleep;  oftentimes  a  change  to  the  bed 
of  the  nurse  or  mother  for  the  remainder  of 
the  night  will  be  all  that  is  necessary;  or  a 
light  may  be  left  burning  in  the  room.  The 
attacks  may  usually  be  prevented  by  a  suit- 
able diet.  The  evening  meal  should  be  very 
light — a  cereal  with  milk  and  a  little  stewed 
fruit  is  sufficient.  This  light  supper  has  re- 
lieved several  of  my  patients  of  habitual  night 
terrors.  Constipation  is  often  an  important 
factor,  and  when  present  requires  treatment 
before  relief  is  to  be  expected. 

SCALES  FOR  WEIGHING 

A  scale  for  weighing  the  baby  is  a  very 
necessary  adjunct  to  the  nursery  furnishings. 


Scales  for  Weighing        307 

There  are,  on  the  market,  several  varieties 
of  scales  for  weighing  the  baby,  which  are 
known  as  "baby  scales."  The  usual  construc- 
tion is  that  of  a  basket,  into  which  the  baby 


FIG.    20.       SCOOP   AND    PLATFORM    SCALES    FOR    WEIGHING 

is  placed,  supported  by  a  rod  which  rests  upon 
a  spring.  A  needle  indicates  on  a  dial  the 
weight  of  the  child.  The  use  of  these  scales 
is  not  to  be  advised.  They  get  out  of  order 
easily,  are  expensive,  and  with  a  vigorous, 
kicking,  crying  baby,  the  rapid  oscillations  of 
the  needle  often  prevent  the  weight  being  read 
with  any  degree  of  accuracy.  Further,  their 
weight  capacity  is  but  twenty  pounds.  When 
the  child's  weight  reaches  this  figure,  it  necessi- 


3o8          The  Exercise  Pen 

tates  the  purchase  of  other  scales.  The  scoop 
and  platform  scales  used  by  grocers  (see  Fig. 
20)  answer  the  purpose  far  better  than  any 
others.  They  do  not  get  out  of  order,  and 
weigh  correctly  from  one-half  ounce  to  two 
hundred  and  eighty  pounds.  The  infant  rests 
on  his  back  in  the  scoop  during  the  weighing 
process.  Older  children  stand  on  the  platform. 

THE  EXERCISE  PEN 

In  a  previous  chapter,  in  speaking  of  cold 
and  how  children  were  exposed  to  influences 
which  might  bring  about  what  is  known  as  a 
"cold,"  the  custom  of  allowing  a  child  to  sit 
on  the  floor  is  referred  to. 

To  keep  a  child  from  eight  to  twenty-four 
months  of  age  off  the  floor  during  the  winter 
months,  and  thereby  prevent  his  taking  cold, 
is  a  very  difficult  matter.  In  fact,  with  active 
children  who  are  learning  to  walk,  or  who  have 
just  learned  to  walk,  it  is  practically  impossible. 
During  this  season  of  the  year  there  is  always 
a  current  of  cold  air  near  the  floor,  and  allow- 
ing the  child  to  creep  on  the  floor  in  winter, 
even  if  it  is  protected  by  rug  and  pillows,  is 
one  of  the  surest  ways  of  taking  cold.  If  he 


The  Exercise  Pen          309 

is  allowed  to  walk  on  the  floor  he  is  very  sure 
to  sit  down  in  a  very  few  minutes.  If  he  is 
not  allowed  to  creep  and  walk  about  at  will  he 
will  not  get  the  proper  exercise,  and  will  show 
faulty  development;  for  such  cases  I  have 
found  the  exercise  pen  (see  Fig.  21)  of  im- 
mense service.  After  being  dressed,  washed, 
and  fed,  the  infant  is  placed  in  the  pen  on  a 
rug  or  quilt,  toys  are  given  him,  and  the  door 
closed.  He  can  now  roam  about  at  will,  stand 
up,  sit  down,  roll,  creep,  or  walk  without  dan- 
ger of  physical  harm  from  rolling  down-stairs, 
being  burned,  or  being  stepped  on.  He  is  thus 
given  an  opportunity  for  active  exercise  with- 
out a  possible  chance  of  injury. 

A  young  mother  of  two  children  will  take 
her  "pen"  into  the  country  in  the  summer  and 
place  it  in  the  shade  for  use  while  the  dew  is 
on  the  grass.  In  case  the  nursery  is  small  it 
can  be  made  so  as  to  fit  over  the  nurse's  bed 
and  consequently  does  not  require  any  addi- 
tional space.  In  a  large  nursery  it  can  be 
placed  permanently  in  one  corner  of  the  room, 
thus  avoiding  the  trouble  of  putting  it  up  and 
taking  it  down. 

The  pen  can  be  made  of  any  size, — 4  x  6  ft. 
is  probably  the  most  convenient,  although 


Dont's 


several  made  4x4  ft.  are  in  use.  It  is  so  con- 
structed as  to  be  taken  apart  and  put  together 
in  a  few  moments,  iron  tenon  hooks  and  iron 
mortices  being  used  to  hold  the  parts  together. 
The  floor  may  be  made  of  any  thin  material. 
One-quarter  inch  pine  boards  nailed  together 
so  that  the  floor  will  be  composed  of  two  thick- 
nesses, or  papier-mache  supported  by  narrow 
strips  of  board,  may  be  used.  The  floor  is 
supported  by  strips  of  board  about  one-half 
by  two  inches,  which  are  fastened  to  the  inner 
side  of  the  end-pieces. 

DON'TS 

Do  not  kiss  the  baby  on  the  mouth  or  allow 
your  friends  to  do  so. 

Do  not  give  soothing  syrups  or  paregoric. 

Do  not  give  proprietary  cough  medicines. 

Do  not  fail  to  secure  the  best  milk  you  can 
afford  to  buy. 

Do  not  allow  flies  to  rest  on  feeding  bottle 
or  nipple. 

Do  not  fail  to  wash  the  hands  before  pre- 
paring the  food. 

Do  not  neglect  to  properly  cleanse  the  bottle 
and  nipple. 


312  Don'ts 

Do  not  allow  the  milk  bottle  to  remain  un- 
covered or  off  the  ice. 

Do  not  fail  to  keep  the  food  on  the  ice  after 
it  is  prepared. 

Do  not  feed  the  baby  at  irregular  in- 
tervals. 

Do  not  fail  to  change  the  napkin  as  soon  as 
it  is  soiled. 

Do  not  fail  to  protect  the  baby  from  flies 
and  mosquitoes  by  suitable  mosquito  netting. 

Do  not  give  the  baby  a  pacifier. 

Do  not  place  the  spoon  or  nipple  to  the  lips 
before  giving  it  to  the  child. 

Do  not  allow  the  baby  to  pick  objects  from 
the  floor  and  place  them  in  his  mouth. 

Do  not  allow  the  baby  to  go  one  day  without 
a  bowel  movement. 

Do  not  neglect  the  daily  care  of  the 
mouth. 

Do  not  excite  the  baby  during  or  immedi- 
ately after  feeding. 

Do  not  raise  the  baby  without  supporting 
the  back. 

Do  not  neglect  to  powder  all  folds  of  the 
skin. 

Do  not  neglect  to  keep  the  ice-box  clean 
and  filled  with  ice. 


General  Instructions        3X3 

GENERAL  INSTRUCTIONS 

How  to  give  an  eneww. — Make  a  suds  of 
water  and  Castile  soap.  Pour  one  pint  water 
into  the  bag  of  a  fountain  syringe.  Introduce 
into  the  anus  the  black  rubber  tip  lubricated 
with  vaseline.  Raise  the  bag  two  feet  above  the 
child's  head  and  allow  the  water  in  part  or  en- 
tire to  pass  into  the  intestine. 

How  to  cleanse  the  eyes. — Dip  clean  absorb- 
ent cotton  in  boracic  acid  solution,  teaspoonful 
to  one  glass  of  water  (dissolved  with  hot 
water)  ;  the  solution  may  be  used  cool  or  luke- 
warm. Use  a  fresh  piece  of  cotton  for  each 
eye. 

How  to  cleanse  the  baby's  nose. — Wrap 
loosely  a  bit  of  absorbent  cotton  on  a  wooden 
toothpick.  Dip  the  cotton  in  vaseline  and  with 
the  baby's  head  held  firmly  introduce  the  cotton 
into  the  nostrils  and  through  very  gentle 
manipulation  remove  the  crusts  and  secretions 
that  may  have  formed  there.  Use  fresh  cotton 
for  each  nostril. 

How  to  syringe  the  ears. — Necessary  arti- 
cles :  A  two-quart  fountain  syringe  and  a 
small  basin. 

The  child  should  be  wrapped  in  a  sheet  with 


3H  Food  Formulas 

the  arms  bound  to  the  side.  He  should  rest 
on  his  back  on  the  bed  or  couch.  The  basin 
protected  by  a  towel  is  placed  under  the  ear. 
Into  the  bag  of  the  syringe  is  poured  the  solu- 
tion to  be  used  for  the  douching.  The  bag  is 
held  three  feet  above  the  child's  head.  The 
small  black  rubber  tip  is  held  about  one-fourth 
inch  from  the  orifice  of  the  ear  canal  and  the 
solution  allowed  to  flow.  The  ear  should  be 
drawn  slightly  backward  and  upward  as  this 
straightens  the  canal  and  allows  of  a  freer  flow 
of  water. 

FOOD  FORMULAS 

Beef-juice. — Broil  round  steak  very  rare, 
cut  into  small  pieces,  place  in  a  meat-press, 
and  press  out  the  blood ;  add  a  little  salt. 

Beef,  mutton,  and  chicken  broth. — Take  one 
pound  of  meat  free  from  fat,  cook  for  three 
hours  in  one  quart  of  water,  adding  water 
from  time  to  time,  so  that  when  the  cooking 
is  completed  there  will  be  one  pint  of  broth. 
When  the  broth  is  cool,  remove  the  fat,  strain 
and  add  salt. 

Scraped  beef. — Broil  round  steak  slightly 
over  a  brisk  fire.  Split  the  steak  and  scrape 
out  pulp,  using  a  tablespoon. 


Food  Formulas  3J5 

Egg-water. — The  white  of  one  egg,  thor- 
oughly beaten  in  one  pint  of  cold  boiled  water, 
strain,  add  a  pinch  of  salt. 

Oatmeal  jelly. — Oatmeal,  two  ounces ;  water, 
one  pint;  boil  for  three  hours  in  a  double 
boiler,  water  being  added,  so  that  when  the 
cooking  is  completed  a  thin  paste  will  be 
formed.  This  while  hot  is  forced  through 
a  colander  to  remove  the  coarser  particles. 
When  cold,  a  semi-solid  mass  will  be  formed. 

Wheat  jelly  and  barley  jelly. — Wheat  jelly 
and  barley  jelly  are  made  in  the  same  way 
as  oatmeal  jelly,  using  cracked  wheat  or  bar- 
ley grains. 

Barley-water. — Robinson's  barley  flour  or 
Cereo  Co.'s  barley  flour,  one  rounded  table- 
spoonful;  water,  one  pint;  boil  thirty  minutes, 
strain,  add  water  to  make  one  pint.  The 
barley  should  be  well  blended  with  a  small 
quantity  of  cold  water,  making  a  paste,  and 
then  added  to  sufficient  water  to  make  one 
pint. 

Rice-water. — Rice,  one  tablespoonf ul ;  water, 
one  pint;  boil  three  hours,  adding  water  from 
time  to  time,  so  that  there  is  one  pint  of  rice- 
water  at  the  end  of  three  hours. 

Dextrinized  barley-water. — Robinson's  bar- 


316  Food  Formulas 

ley  flour  or  Cereo  barley  flour,  three  table- 
spoonfuls;  water,  one  pint;  boil  twenty  min- 
utes, add  water  to  make  a  pint.  When  luke- 
warm (ioo°F.)  add  one  teaspoonful  of 
Cereo,  strain ;  this  changes  the  starch  into  dex- 
trinized  maltose. 

Oatmeal-water. — Oatmeal,  one  tablespoon- 
f ul ;  water,  one  pint ;  cook  three  hours  and  add 
water  to  make  one  pint.  The  granum  should 
be  well  blended  with  a  small  quantity  of  cold 
water,  making  a  paste,  and  then  added  to  suffi- 
cient water  to  make  one  pint. 

Imperial  granum-water. — Imperial  granum, 
one  tablespoonf ul ;  water,  one  pint ;  cook  thirty 
minutes  and  add  water  to  make  one  pint. 

Whey. — Put  one  pint  of  fresh  milk  into  a 
saucepan  and  heat  it  lukewarm,  not  over  100° 
F. ;  then  add  two  (2)  teaspoonfuls  of  Fair- 
child's  essence  of  pepsin  and  stir  just  enough 
to  mix.  Let  it  stand  until  firmly  jellied,  then 
beat  with  a  fork  until  it  is  finely  divided,  strain, 
and  the  whey,  the  liquid  part,  is  ready  for 
use. 

Junket. — Heat  one  pint  of  milk  to  100°  F. 
Add  one  junket  tablet  previously  dissolved  in 
a  little  water  or  two  teaspoons  of  essence  of 
pepsin,  two  teaspoons  of  sugar,  and  a  few 


Prun,e  Juice  317 

drops  essence  of  vanilla.  Allow  to  stand  per- 
fectly quiet  until  the  curd  is  set,  when  it  should 
be  placed  on  the  ice. 

Cornstarch  'pudding.  —  Dissolve  one  table- 
spoonful  of  cornstarch  in  a  little  milk.  Heat 
one  pint  of  milk  to  nearly  boiling  point.  Add 
cornstarch  slowly,  then  one  tablespoon  ful 
of  sugar  and  stir  until  it  thickens.  When 
cool  add  5  drops  of  flavoring. 

Soft  custard. — Heat  one  cup  of  milk  to  boil- 
ing point.  Add  one  yolk  of  egg  well  beaten, 
one  teaspoonful  of  sugar  and  a  pinch  of  salt. 
Cook  in  a  double  boiler,  stirring  until  it 
thickens.  Strain  and  add  five  drops  of  flavor- 
ing. 

PRUNE  JUICE 

Take  one  pound  of  prunes,  wash  thoroughly, 
place  in  a  pan,  cover  with  cold  water  and  allow 
to  stand  over  night.  Place  on  stove  next  morn- 
ing, bring  to  a  boil  and  allow  to  simmer  until 
very  soft.  Strain  off  the  juice  (which  should 
be  eight  ounces  juice)  and  give  the  required 
amount  for  the  infant. 

For  older  children  the  pulp  may  be  used 
with  the  juice  after  putting  through  a  sieve. 


3i8  Coddled  Egg 

CODDLED  EGG 

Take  a  fresh  egg,  place  it  in  a  pan  of  boiling 
water,  put  on  the  back  of  the  stove  and  stand 
for  three  minutes,  having  pan  tightly  covered. 


THE   END 


M  Selection  from  the 
Catalogue  of 

G.  P.  PUTNAM'S   SONS 


Complete  Catalogues  sent 
on  application 


1000  Things  a  Mother 
Should  Know 

By 
Mae  Savell  Croy 

Author  of  "  1000  Shorter  Ways  Around  the  House/'  etc. 


Information  is  given  regarding  tiny  babies 
and  growing  children:  their  clothes,  their 
care,  their  food,  their  training,  and  their  en- 
tertainment. The  book  embraces  everything 
from  the  prenatal  precautions  to  be  observed 
by  the  prospective  mother  to  the  rearing  of 
the  child  to  a  healthy  adolescence.  Not  only 
are  the  bodily  needs  intelligently  specified,  but 
the  character-building  influences  that  should 
surround  the  child  are  conveyed  in  the  excel- 
lent suggestions  offered.  Health  rules  and 
medical  care,  hygiene  and  sick-room  sugges- 
tions, are  a  valuable  supplement  to  the  chap- 
ters dealing  with  the  treatment  of  the  child 
when  in  health.  Arranged  under  appropriate 
headings  and  comprehensively  indexed. 


G.  P.  Putnam's  Sons 
New  York  London 


Radiant 
Motherhood 

Jl  Book  for  Those  Who  are 
Creating  the  Future 

By  Marie  Carmichael  Stopes 

Doctor  of  Science,  London;  Doctor  of  Philosophy,  Munich; 
Fellow  of  University  College,  London;  Fellow  of  the  Royal 
Society  of  Literature;  and  the  Linn  can  Society,  London 

In  "Radiant  Motherhood"  the  joys  and  diffi- 
culties of  young  parents  are  treated  with 
helpful  perception,  the  glory,  power  and 
sacrifice  of  motherhood  are  made  clear  by 
dealing  frankly  with  the  physical  and  psy- 
chological states  of  the  mother  to-be;  nor  is 
the  father  to-be  forgotten,  as  the  author  dis- 
plays her  power  of  understanding  and  helping 
to  remove  the  difficulties  and  distresses  of  the 
young  husband. 

The  chapters  are  of  unique  help  to  the  mod- 
ern man  and  woman  by  separating  clearly 
(1)  the  nature-imposed  difficulties  from  (2) 
those  entirely  artificial,  and  (3)  those  which 
are  to-day  general,  but  which  by  knowledge 
can  be  completely  conquered.  The  author 
creates  round  the  subject  the  light  of  beauty 
and  joy  springing  from  true  understanding. 

Were  all  mothers  and  fathers  to  know  what  is  in 
this  book,  and  use  its  wisdom,  a  few  decades  would 
see  the  human  race  transformed  and  irradiated. 

G.  P.  Putnam's  Sons 
New  York  London 


*m  2*  ffl. 


AU8  18  929 


1\**6 


1956 


I  jo 


UNIVERSITY  OF  CALIFORNIA  LIBRARY 


